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Inada M, Iwamoto N, Nomoto H, Tsuzuki S, Takemoto N, Fuwa N, Moriya A, Ohmagari N. Characteristics of Streptococcal Toxic Shock Syndrome Caused by Different Beta-hemolytic Streptococci Species: A Single-center Retrospective Study. Open Forum Infect Dis 2024; 11:ofae486. [PMID: 39296344 PMCID: PMC11409875 DOI: 10.1093/ofid/ofae486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Accepted: 08/26/2024] [Indexed: 09/21/2024] Open
Abstract
Background Streptococcal toxic shock syndrome (STSS) is a life-threatening condition caused by beta-hemolytic streptococci (BHS). Streptococcus pyogenes is the main causative agent of this disease; other BHS such as Streptococcus agalactiae or Streptococcus dysgalactiae could also cause STSS. However, the clinical characteristics of STSS caused by other types of BHS remain poorly understood. In this study, we evaluated the likelihood of STSS development in various streptococcal species. Methods We conducted a retrospective observational study using adult medical records of patients with invasive BHS in a tertiary care institution from 2002 to 2022 and classified them into STSS or non-STSS groups. Multivariable analysis of bacterial species adjusted for age and diabetes mellitus was conducted. S pyogenes cases were propensity-matched (1:4) to non-pyogenes BHS cases. Results A total of 43 STSS and 285 non-STSS cases were identified. S pyogenes, S agalactiae, and S dysgalactiae accounted for 17, 13, and 13 STSS cases, respectively. The crude mortality of STSS was approximately 35% in all groups. A multivariable analysis suggested that STSS was less frequent in S agalactiae and S dysgalactiae cases with odds ratio 0.24 (95% confidence interval [CI], 0.10-0.54; P < .001) and 0.23 (95% CI, .10-.55; P < .001), respectively. Propensity score matching showed that S pyogenes caused STSS more frequently than other BHS cases with an odds ratio of 3.28 (95% CI 1.21-8.77; P = .010). Conclusions This study described and compared the clinical characteristics of STSS caused by different BHS. We demonstrated that S pyogenes caused STSS more often than other BHS.
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Affiliation(s)
- Makoto Inada
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Noriko Iwamoto
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
- AMR Clinical Reference Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Hidetoshi Nomoto
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Shinya Tsuzuki
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
- AMR Clinical Reference Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Norihiko Takemoto
- Department of Infectious Diseases, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan
| | - Noriko Fuwa
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Ataru Moriya
- Laboratory Testing Department, National Center for Global Health and Medicine, Tokyo, Japan
| | - Norio Ohmagari
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
- AMR Clinical Reference Center, National Center for Global Health and Medicine, Tokyo, Japan
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2
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Choudhary OP. Emergence of STSS in Japan: An assessment of the threat and containment strategies. New Microbes New Infect 2024; 60-61:101449. [PMID: 39045289 PMCID: PMC11263716 DOI: 10.1016/j.nmni.2024.101449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Accepted: 06/24/2024] [Indexed: 07/25/2024] Open
Affiliation(s)
- Om Prakash Choudhary
- Department of Veterinary Anatomy, College of Veterinary Science, Guru Angad Dev Veterinary and Animal Sciences University, Rampura Phul, Bathinda, 151103, Punjab, India
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Niwa A, Hayashi M, Yonetamari J, Nakamura M, Yokobori Y, Yokoyama S, Ogawa M, Ichioka R, Kikuchi R, Okura H, Ogura S, Tetsuka N, Tanaka K, Baba H. First Case of Necrotizing Fasciitis and Septicemia Caused by Pigmentibacter ruber. Jpn J Infect Dis 2024; 77:244-246. [PMID: 38417864 DOI: 10.7883/yoken.jjid.2023.370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2024]
Abstract
We report the first case of necrotizing fasciitis caused by Pigmentibacter ruber. The isolated strain could not be identified by biochemical characterization or matrix-assisted laser desorption/ionization time-of-flight mass spectrometry but was identified as P. ruber by 16S ribosomal RNA and whole-genome sequencing. Although much remains unknown about the pathogenicity of this bacterial species in humans, it has been shown to cause life-threatening infections such as septicemia and necrotizing fasciitis. Because the isolate was highly resistant to β-lactams, it was difficult to treat with antimicrobial therapy. Thus, further documentation of cases and analyses are required.
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Affiliation(s)
- Ayumi Niwa
- Division of Clinical Laboratory, Gifu University Hospital, Japan
| | - Masahiro Hayashi
- Gifu University Center for Conservation of Microbial Genetic Resource, Japan
| | - Jun Yonetamari
- Division of Clinical Laboratory, Gifu University Hospital, Japan
| | | | - Yuta Yokobori
- Division of Clinical Laboratory, Gifu University Hospital, Japan
| | - Sodai Yokoyama
- Division of Clinical Laboratory, Gifu University Hospital, Japan
| | - Mizuki Ogawa
- Division of Clinical Laboratory, Gifu University Hospital, Japan
| | - Rina Ichioka
- Division of Clinical Laboratory, Gifu University Hospital, Japan
| | - Ryosuke Kikuchi
- Division of Clinical Laboratory, Gifu University Hospital, Japan
| | - Hiroyuki Okura
- Department of Cardiology, Gifu University Graduate School of Medicine, Japan
| | - Shinji Ogura
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Japan
| | - Nobuyuki Tetsuka
- Department of Infection Control, Gifu University Graduate School of Medicine, Japan
| | - Kaori Tanaka
- Gifu University Center for Conservation of Microbial Genetic Resource, Japan
| | - Hisashi Baba
- Center for Nutrition Support and Infection Control, Gifu University Hospital, Japan
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4
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Rajack F, Medford S, Ramadan A, Naab T. Emerging infection: streptococcal toxic shock-like syndrome caused by group B Streptococcus (GBS), Streptococcus agalactiae. Autops Case Rep 2024; 14:e2024497. [PMID: 39021470 PMCID: PMC11253910 DOI: 10.4322/acr.2024.497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 04/25/2024] [Indexed: 07/20/2024]
Abstract
Streptococcus agalactiae or Group B Streptococcus (GBS) infections are commonly associated with infections in neonates and pregnant women. However, there has been a rising incidence in nonpregnant adults. The risk of GBS infection in nonpregnant adults is increased for patients of advanced age and those with underlying medical conditions such as diabetes mellitus and cancer. We present a 77-year-old female with type-2 diabetes mellitus, hypertension, and bilateral foot ulcers that presented in probable septic shock with necrotic foot ulcers and necrotizing fasciitis and underwent bilateral lower limb amputations. The patient fulfilled the Streptococcal Toxic Shock Syndrome (STSS) criteria as defined by The Working Group on Severe Streptococcal Infections. These criteria were created for group A Streptococcus (Streptococcus pyogenes). Our patient fulfilled the Working Group's criteria, except that the blood culture was positive for group B Streptococcus (Streptococcus agalactiae). Numerous studies demonstrate the importance of early detection and antibiotic treatment for GBS infections in general and early surgical management for necrotizing soft tissue infections (NSTIs) such as necrotizing fasciitis.
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Affiliation(s)
- Fareed Rajack
- Howard University Hospital, Department of Pathology and Laboratory Medicine, Washington, D.C., United States of America
| | - Shawn Medford
- Howard University College of Medicine, Washington, D.C., United States of America
| | - Ali Ramadan
- Howard University Hospital, Department of Pathology and Laboratory Medicine, Washington, D.C., United States of America
| | - Tammey Naab
- Howard University Hospital, Department of Pathology and Laboratory Medicine, Washington, D.C., United States of America
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5
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Onigahara M, Yanazume S, Torisu H, Kobayashi H. Invasive group A streptococcal infection can be fatal to pregnant women in restricted medical resources remote areas-Emergent alert after COVID-19 pandemic. J Obstet Gynaecol Res 2024; 50:1061-1066. [PMID: 38561215 DOI: 10.1111/jog.15934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 03/15/2024] [Indexed: 04/04/2024]
Abstract
Invasive group A streptococcal (iGAS) infection is a leading cause of maternal death. The increase in the number of patients with iGAS in Japan is markedly greater than before the coronavirus pandemic. We encountered a case of iGAS infection, on a remote island with restricted medical resources, in a third-trimester pregnant woman, resulting in both maternal and fetal death. A 34-year-old woman was admitted via a local general hospital with a high fever. Intrauterine fetal death disseminated intravascular coagulation, and septic shock were confirmed. Broad-spectrum antibiotics were started, and the patient was returned to the local general hospital. Eight hours after arrival, the patient died of circulatory and respiratory dysfunction complications. iGAS infections in remote areas may directly lead to life-threatening conditions and should be treated as an emergency, comparable to the serious conditions of placental abruption or placenta previa.
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Affiliation(s)
| | - Shintaro Yanazume
- Department of Obstetrics & Gynecology, Faculty of Medicine, Kagoshima University, Kagoshima, Japan
| | | | - Hiroaki Kobayashi
- Department of Obstetrics & Gynecology, Faculty of Medicine, Kagoshima University, Kagoshima, Japan
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6
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Kim TH. Toxic Shock Syndrome (TSS) Caused by Group A Streptococcus: Novel Insights Within the Context of a Familiar Clinical Syndrome. J Korean Med Sci 2024; 39:e154. [PMID: 38711318 PMCID: PMC11074494 DOI: 10.3346/jkms.2024.39.e154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Accepted: 04/12/2024] [Indexed: 05/08/2024] Open
Abstract
The emergence of invasive infections attributed to group A Streptococcus (GAS) infections, has resurged since the 1980s. The recent surge in reports of toxic shock syndrome due to GAS in Japan in 2024, while sensationalized in the media, does not represent a novel infectious disease per se, as its diagnosis, treatment, and prevention are already well-established. However, due to signs of increasing incidence since 2011, further research is needed. Health authorities in neighboring countries like The Republic of Korea should not only issue travel advisories but also establish meticulous surveillance systems and initiate epidemiological studies on the genotypic variations of this disease while awaiting various epidemiological research findings from Japan.
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Affiliation(s)
- Tae Hyong Kim
- Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea.
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7
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Hamid SA, Graetz E, Schneider E, Gibbs KE. A Cross-Sectional Analysis of Pediatric Necrotizing Soft Tissue Infection Cases and Racial Disparities From the 2016 to 2020 National Inpatient Sample. J Surg Res 2024; 297:136-143. [PMID: 38518580 DOI: 10.1016/j.jss.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 01/05/2024] [Accepted: 02/16/2024] [Indexed: 03/24/2024]
Abstract
INTRODUCTION The incidence, treatment, and outcomes of necrotizing soft tissue infections (NSTIs) and associated racial disparities have been described in adults, but research in the pediatric population is limited. The purpose of this study is to provide a nationally representative characterization of pediatric NSTI and determine the presence of any racial disparities. METHODS The National Inpatient Sample was analyzed from 2016 through 2020. Patients aged less than 20 y with a diagnosis of necrotizing fasciitis, Fournier's gangrene, or gas gangrene (based on International Classification of Diseases, Tenth Revision, Clinical Modification codes) were included for analysis. RESULTS A total of 355 patients were identified. Black and Hispanic patients accounted for the most admissions in 2016 and 2018, respectively (P = 0.024). Compared to White patients, more Black patients were insured by Medicaid (P = 0.037) and were in the first zip code-based income quartile (P = 0.005). The leading infection overall was necrotizing fasciitis and most patients (81.7%) underwent a surgical procedure by the first calendar day after admission. Although the proportion of Black patients undergoing subcutaneous tissue and fascia excisions was more than that of White patients (P = 0.005), there were no significant differences by race in the time to first procedure, the total number of procedures, or number of postoperative complications. Our amputation and mortality rates were low and unreportable, but there were no differences by race. CONCLUSIONS NSTI is rare in the pediatric population and mortality is low. Black patients are disproportionately diagnosed, but these disparities do not extend to disease treatment or outcomes.
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Affiliation(s)
- Safraz A Hamid
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut.
| | - Elena Graetz
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Eric Schneider
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Karen E Gibbs
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
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8
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Allaw F, Wehbe S, Kanj SS. Necrotizing fasciitis: an update on epidemiology, diagnostic methods, and treatment. Curr Opin Infect Dis 2024; 37:105-111. [PMID: 38037890 DOI: 10.1097/qco.0000000000000988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
PURPOSE OF REVIEW The aim of this review is to discuss the latest evidence of epidemiology, diagnostic methods, and treatment of necrotizing soft tissue infections (NSTIs) with a particular focus on necrotizing fasciitis (NF). RECENT FINDINGS NSTIs have been historically referred to as NF but encompass a broader range of infections, with variable rates ranging from 0.86 to 32.64 per 100 000 person-years, influenced by factors such as climate and seasonal variations. They have diverse microbiological profiles categorized into different types based on the involved pathogens, including polymicrobial or monomicrobial infections caused by organisms such as group A streptococcus (GAS), Staphylococcus aureus , some Gram-negative pathogens, and filamentous fungi following trauma and natural disasters. Diagnosis relies on clinical symptoms and signs, laboratory markers, and imaging. However, the gold standard for diagnosis remains intraoperative tissue culture. Treatment involves repeated surgical debridement of necrotic tissues in addition to intravenous antibiotics. Adjuvant therapies with intravenous immunoglobulin (IVIG) and hyperbaric oxygen therapy (HBOT) might have a role. Soft tissue reconstruction may be necessary following surgery. SUMMARY Prompt diagnosis and proper medical and surgical management of NSTI will improve outcomes.
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Affiliation(s)
- Fatima Allaw
- Division of Infectious Diseases, Department of Internal Medicine, American University of Beirut Medical Center
| | - Saliba Wehbe
- Division of Infectious Diseases, Department of Internal Medicine, American University of Beirut Medical Center
| | - Souha S Kanj
- Division of Infectious Diseases, Department of Internal Medicine, American University of Beirut Medical Center
- Center for Infectious Disease Research, American University of Beirut, Beirut, Lebanon
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9
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Ruiz-Rodríguez JC, Chiscano-Camón L, Maldonado C, Ruiz-Sanmartin A, Martin L, Bajaña I, Bastidas J, Lopez-Martinez R, Franco-Jarava C, González-López JJ, Ribas V, Larrosa N, Riera J, Nuvials-Casals X, Ferrer R. Catastrophic Streptococcus pyogenes Disease: A Personalized Approach Based on Phenotypes and Treatable Traits. Antibiotics (Basel) 2024; 13:187. [PMID: 38391573 PMCID: PMC10886101 DOI: 10.3390/antibiotics13020187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 02/07/2024] [Accepted: 02/09/2024] [Indexed: 02/24/2024] Open
Abstract
Streptococcal toxic shock syndrome (STTS) is a critical medical emergency marked by high morbidity and mortality, necessitating swift awareness, targeted treatment, and early source control due to its rapid symptom manifestation. This report focuses on a cohort of 13 patients admitted to Vall d'Hebron University Hospital Intensive Care Unit, Barcelona, from November 2022 to March 2023, exhibiting invasive Streptococcus pyogenes infections and meeting institutional sepsis code activation criteria. The primary infections were community-acquired pneumonia (61.5%) and skin/soft tissue infection (30.8%). All patients received prompt antibiotic treatment, with clinical source control through thoracic drainage (30.8%) or surgical means (23.1%). Organ support involved invasive mechanical ventilation, vasopressors, and continuous renal replacement therapy as per guidelines. Of note, 76.9% of patients experienced septic cardiomyopathy, and 53.8% required extracorporeal membrane oxygenation (ECMO). The study identified three distinct phenotypic profiles-hyperinflammatory, low perfusion, and hypogammaglobulinemic-which could guide personalized therapeutic approaches. STTS, with a mean SOFA score of 17 (5.7) and a 53.8% requiring ECMO, underscores the need for precision medicine-based rescue therapies and sepsis phenotype identification. Integrating these strategies with prompt antibiotics and efficient source control offers a potential avenue to mitigate organ failure, enhancing patient survival and recovery in the face of this severe clinical condition.
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Affiliation(s)
- Juan Carlos Ruiz-Rodríguez
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- Departament of Medicine, Universitat Autonoma de Barcelona, 08193 Barcelona, Spain
| | - Luis Chiscano-Camón
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- Departament of Medicine, Universitat Autonoma de Barcelona, 08193 Barcelona, Spain
| | - Carolina Maldonado
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
| | - Adolf Ruiz-Sanmartin
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
| | - Laura Martin
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
| | - Ivan Bajaña
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
| | - Juliana Bastidas
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
| | - Rocio Lopez-Martinez
- Immunology Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
| | - Clara Franco-Jarava
- Immunology Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
| | - Juan José González-López
- Microbiology Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
| | - Vicent Ribas
- Eurecat, Centre Tecnològic de Catalunya, EHealth Unit, 08005 Barcelona, Spain
| | - Nieves Larrosa
- Microbiology Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
| | - Jordi Riera
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
| | - Xavier Nuvials-Casals
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
| | - Ricard Ferrer
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain
- Departament of Medicine, Universitat Autonoma de Barcelona, 08193 Barcelona, Spain
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Atchade E, De Tymowski C, Grall N, Tanaka S, Montravers P. Toxic Shock Syndrome: A Literature Review. Antibiotics (Basel) 2024; 13:96. [PMID: 38247655 PMCID: PMC10812596 DOI: 10.3390/antibiotics13010096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 01/15/2024] [Accepted: 01/16/2024] [Indexed: 01/23/2024] Open
Abstract
Toxic shock syndrome (TSS) is a rare, life-threatening, toxin-mediated infectious process linked, in the vast majority of cases, to toxin-producing strains of Staphylococcus aureus or Streptococcus pyogenes. The pathophysiology, epidemiology, clinical presentation, microbiological features, management and outcome of TSS are described in this review. Bacterial superantigenic exotoxins induces unconventional polyclonal lymphocyte activation, which leads to rapid shock, multiple organ failure syndrome, and death. The main described superantigenic exotoxins are toxic shock syndrome toxin-1 (TSST-1) and enterotoxins for Staphylococcus aureus and Streptococcal pyrogenic exotoxins (SpE) A, B, and C and streptococcal superantigen A (SsA) for Streptococcus pyogenes. Staphylococcal TSS can be menstrual or nonmenstrual. Streptococcal TSS is linked to a severe group A streptococcal infection and, most frequently, to a necrotizing soft tissue infection. Management of TSS is a medical emergency and relies on early detection, immediate resuscitation, source control and eradication of toxin production, bactericidal antibiotic treatment, and protein synthesis inhibiting antibiotic administration. The interest of polyclonal intravenous immunoglobulin G administration as an adjunctive treatment for TSS requires further evaluation. Scientific literature on TSS mainly consists of observational studies, clinical cases, and in vitro data; although more data on TSS are required, additional studies will be difficult to conduct due to the low incidence of the disease.
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Affiliation(s)
- Enora Atchade
- DMU PARABOL, Bichat-Claude Bernard Hospital, AP-HP, 75018 Paris, France; (C.D.T.); (S.T.); (P.M.)
| | - Christian De Tymowski
- DMU PARABOL, Bichat-Claude Bernard Hospital, AP-HP, 75018 Paris, France; (C.D.T.); (S.T.); (P.M.)
- UFR Diderot, Paris Cité University, 75018 Paris, France;
- INSERM UMR 1149, Immunoreceptor and Renal Immunopathology, Bichat-Claude Bernard Hospital, 75018 Paris, France
| | - Nathalie Grall
- UFR Diderot, Paris Cité University, 75018 Paris, France;
- Bacteriology Department, Bichat Claude Bernard Hospital, AP-HP, Paris Cité University, 75018 Paris, France
- INSERM UMR 1137 Infection, Antimicrobials, Modelling, Evolution, 75018 Paris, France
| | - Sébastien Tanaka
- DMU PARABOL, Bichat-Claude Bernard Hospital, AP-HP, 75018 Paris, France; (C.D.T.); (S.T.); (P.M.)
- INSERM, UMR 1188, Diabetes Atherothrombosis Réunion Océan Indien (DéTROI), la Réunion University, 97400 Saint-Denis de la Réunion, France
| | - Philippe Montravers
- DMU PARABOL, Bichat-Claude Bernard Hospital, AP-HP, 75018 Paris, France; (C.D.T.); (S.T.); (P.M.)
- UFR Diderot, Paris Cité University, 75018 Paris, France;
- INSERM UMR 1152 ANR 10—LABX-17, Pathophysiology and Epidemiology of Respiratory Diseases, 75018 Paris, France
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11
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Sakaguchi YM, Murakami K, Akebo H, Sada RM, Abe N, Maeda T, Goto M, Takahashi T, Takahashi Y, Kashihara E, Shim J, Miyake H, Hatta K. Successful treatment of streptococcal toxic shock syndrome complicated by primary peritonitis and bilateral empyema in a healthy young woman: Identification of uncommon clone emm103 and novel sequence type 1363. IDCases 2024; 35:e01927. [PMID: 38303733 PMCID: PMC10831287 DOI: 10.1016/j.idcr.2024.e01927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 11/13/2023] [Accepted: 01/09/2024] [Indexed: 02/03/2024] Open
Abstract
Streptococcal toxic shock syndrome (STSS) has a dramatic clinical course and high mortality rate. Here, we report a case of STSS complicated by primary peritonitis and bilateral empyema. A previously healthy young woman was diagnosed with STSS complicated by primary peritonitis and bilateral empyema. Blood culture results on admission were negative. Sever shock, respiratory failure, systemic inflammation, thrombocytopenia, renal failure, ascites, and pleural effusion occurred, mimicking thrombocytopenia, anasarca, fever, reticulin fibrosis/renal failure and organomegaly (TAFRO) syndrome. Retesting blood cultures identified Streptococcus pyogenes. Gram staining of ascites and pleural fluid indicated gram-positive cocci in chains. Antibiotics, immunoglobulins, and surgical intervention led to recovery without complications. Ex-post genotypic analyses showed uncommon emm103.0 (cluster E3) of emm long sequence (784 base) and novel sequence type 1363. STSS diagnosis can be difficult as it mimics other systemic inflammatory diseases. Therefore, it is crucial for clinicians to perform microbiological examinations from infection foci, even if the initial culture is negative.
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Affiliation(s)
- Yoshihiko M. Sakaguchi
- Department of General Internal Medicine, Tenri Hospital, Nara, Japan
- International Institute for Integrative Sleep Medicine (WPI-IIIS), University of Tsukuba, Tsukuba, Ibaraki, Japan
- Ph.D. Program in Humanics, School of Integrative and Global Majors, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Koichiro Murakami
- Department of General Internal Medicine, Tenri Hospital, Nara, Japan
| | - Hiroyuki Akebo
- Department of General Internal Medicine, Tenri Hospital, Nara, Japan
| | - Ryuichi Minoda Sada
- Department of General Internal Medicine, Tenri Hospital, Nara, Japan
- Department of Transformative Protection to Infectious Disease, Graduate School of Medicine, Osaka University, Osaka, Japan
- Department of Infection Control, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Noriyuki Abe
- Department of Clinical Laboratory Medicine, Tenri Hospital, Nara, Japan
| | - Takahiro Maeda
- Laboratory of Infectious Diseases, Graduate School of Infection Control Sciences and Ōmura Satoshi Memorial Institute, Kitasato University, Tokyo, Japan
| | - Mieko Goto
- Laboratory of Infectious Diseases, Graduate School of Infection Control Sciences and Ōmura Satoshi Memorial Institute, Kitasato University, Tokyo, Japan
| | - Takashi Takahashi
- Laboratory of Infectious Diseases, Graduate School of Infection Control Sciences and Ōmura Satoshi Memorial Institute, Kitasato University, Tokyo, Japan
| | - Yusuke Takahashi
- Department of General Internal Medicine, Tenri Hospital, Nara, Japan
- Department of Infection Control, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Eriko Kashihara
- Department of General Internal Medicine, Tenri Hospital, Nara, Japan
| | - Jaegi Shim
- Department of General Internal Medicine, Tenri Hospital, Nara, Japan
| | - Hirofumi Miyake
- Department of General Internal Medicine, Tenri Hospital, Nara, Japan
| | - Kazuhiro Hatta
- Department of General Internal Medicine, Tenri Hospital, Nara, Japan
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12
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Guliyeva G, Huayllani MT, Sharma NT, Janis JE. Practical Review of Necrotizing Fasciitis: Principles and Evidence-based Management. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5533. [PMID: 38250213 PMCID: PMC10798703 DOI: 10.1097/gox.0000000000005533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 10/03/2023] [Indexed: 01/23/2024]
Abstract
Necrotizing fasciitis is a severe, life-threatening soft tissue infection that presents as a surgical emergency. It is characterized by a rapid progression of inflammation leading to extensive tissue necrosis and destruction. Nonetheless, the diagnosis might be missed or delayed due to variable and nonspecific clinical presentation, contributing to high mortality rates. Therefore, early diagnosis and prompt, aggressive medical and surgical treatment are paramount. In this review, we highlight the defining characteristics, pathophysiology, diagnostic modalities, current principles of treatment, and evolving management strategies of necrotizing fasciitis.
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Affiliation(s)
- Gunel Guliyeva
- From the Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Maria T. Huayllani
- From the Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Nishant T. Sharma
- From the Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Jeffrey E. Janis
- From the Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
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13
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Takebe K, Suzuki M, Sangawa T, Kreikemeyer B, Yamaguchi M, Uzawa N, Sumitomo T, Kawabata S, Nakata M. Analysis of FctB3 crystal structure and insight into its structural stabilization and pilin linkage mechanisms. Arch Microbiol 2023; 206:4. [PMID: 37994962 DOI: 10.1007/s00203-023-03727-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 10/23/2023] [Accepted: 10/29/2023] [Indexed: 11/24/2023]
Abstract
Streptococcus pyogenes harboring an FCT type 3 genomic region display pili composed of three types of pilins. In this study, the structure of the base pilin FctB from a serotype M3 strain (FctB3) was determined at 2.8 Å resolution. In accordance with the previously reported structure of FctB from a serotype T9 strain (FctB9), FctB3 was found to consist of an immunoglobulin-like domain and proline-rich tail region. Data obtained from structure comparison revealed main differences in the omega (Ω) loop structure and the proline-rich tail direction. In the Ω loop structure, a differential hydrogen bond network was observed, while the lysine residue responsible for linkage to growing pili was located at the same position in both structures, which indicated that switching of the hydrogen bond network in the Ω loop without changing the lysine position is advantageous for linkage to the backbone pilin FctA. The difference in direction of the proline-rich tail is potentially caused by a single residue located at the root of the proline-rich tail. Also, the FctB3 structure was found to be stabilized by intramolecular large hydrophobic interactions instead of an isopeptide bond. Comparisons of the FctB3 and FctA structures indicated that the FctA structure is more favorable for linkage to FctA. In addition, the heterodimer formation of FctB with Cpa or FctA was shown to be mediated by the putative chaperone SipA. Together, these findings provide an alternative FctB structure as well as insight into the interactions between pilin proteins.
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Grants
- 19K22715, 19H03825, 22H03262, 22H03263 JSPS KAKENHI Grants-in-Aid for Scientific Research
- 19K22715, 19H03825, 22H03262, 22H03263 JSPS KAKENHI Grants-in-Aid for Scientific Research
- 19K22715, 19H03825, 22H03262, 22H03263 JSPS KAKENHI Grants-in-Aid for Scientific Research
- 19K22715, 19H03825, 22H03262, 22H03263 JSPS KAKENHI Grants-in-Aid for Scientific Research
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Affiliation(s)
- Katsuki Takebe
- Department of Oral and Maxillofacial Oncology and Surgery, Osaka University Graduate School of Dentistry, 1-8, Yamadaoka, Suita, Osaka, Japan
- Institute for Protein Research, Osaka University, 3-2 Yamadaoka, Suita, Osaka, Japan
- Department of Microbiology, Osaka University Graduate School of Dentistry, 1-8, Yamadaoka, Suita, Osaka, Japan
| | - Mamoru Suzuki
- Institute for Protein Research, Osaka University, 3-2 Yamadaoka, Suita, Osaka, Japan
| | - Takeshi Sangawa
- Institute for Protein Research, Osaka University, 3-2 Yamadaoka, Suita, Osaka, Japan
| | - Bernd Kreikemeyer
- Institute of Medical Microbiology, Virology and Hygiene, University Medicine Rostock, 18057, Rostock, Germany
| | - Masaya Yamaguchi
- Department of Microbiology, Osaka University Graduate School of Dentistry, 1-8, Yamadaoka, Suita, Osaka, Japan
- Bioinformatics Research Unit, Osaka University Graduate School of Dentistry, 1-8, Yamadaoka, Suita, Osaka, Japan
- Bioinformatics Center, Research Institute for Microbial Diseases, Osaka University, 3-1, Yamadaoka, Suita, Osaka, Japan
- Center for Infectious Diseases Education and Research, Osaka University, 2-8, Yamadaoka, Suita, Osaka, Japan
| | - Narikazu Uzawa
- Department of Oral and Maxillofacial Oncology and Surgery, Osaka University Graduate School of Dentistry, 1-8, Yamadaoka, Suita, Osaka, Japan
| | - Tomoko Sumitomo
- Department of Microbiology, Osaka University Graduate School of Dentistry, 1-8, Yamadaoka, Suita, Osaka, Japan
- Department of Oral Microbiology, Graduate School of Biomedical Sciences, Tokushima University, 3-18-15, Kuramoto-cho, Tokushima, Japan
| | - Shigetada Kawabata
- Department of Microbiology, Osaka University Graduate School of Dentistry, 1-8, Yamadaoka, Suita, Osaka, Japan
- Center for Infectious Diseases Education and Research, Osaka University, 2-8, Yamadaoka, Suita, Osaka, Japan
| | - Masanobu Nakata
- Department of Microbiology, Osaka University Graduate School of Dentistry, 1-8, Yamadaoka, Suita, Osaka, Japan.
- Department of Oral Microbiology, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1, Sakuragaoka, Kagoshima, 890-8544, Japan.
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14
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Sokou R, Filippatos F, Daniil V, Bikouli ED, Tsantes AG, Piovani D, Bonovas S, Iliodromiti Z, Boutsikou T, Tsantes AE, Iacovidou N, Konstantinidi A. Group A Streptococcus Infection in Neonatal Population: A Systematic Review of The Literature. J Clin Med 2023; 12:6974. [PMID: 38002589 PMCID: PMC10672068 DOI: 10.3390/jcm12226974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 11/02/2023] [Accepted: 11/04/2023] [Indexed: 11/26/2023] Open
Abstract
(1) Background: The importance of group A streptococcus (GAS) infection severity has been recognized in children and adults. However, to our knowledge, there have been no systematic reviews or pooled assessments of the incidence and outcome of invasive GAS (iGAS) disease in neonates, a potentially high-risk population. Therefore, we performed a systematic review of available data regarding the risk factors, clinical presentation, and outcome of GAS infection in neonates. (2) Methods: An electronic search of the existing literature was carried out during the period July 2023-September 2023 in the PubMed and Scopus databases, considering studies referring to GAS infection in the neonatal population. (3) Results: Overall, 39 studies met all the inclusion criteria and were included in this review, evaluating data from 194 neonates. Unfortunately, there were a lot of missing data among the retrieved studies. Our systematic review highlighted the presence of differences with regards to clinical presentation, infection sites, and outcome of GAS invasive disease between neonates with early-onset (EOS) or late-onset sepsis (LOS). Common characteristics of EOS included respiratory distress, rapid deterioration, and high mortality rate irrespective of the infection site, while rash, gastrointestinal tract symptoms, and fever appeared to be the most frequent symptoms/clinical signs and manifestations of LOS disease. The management of severe invasive iGAS disease consists mainly of specific antimicrobial treatment as well as supportive care with fluids and electrolyte supplementation, minimizing or counteracting the effects of toxins. Furthermore, a mortality rate of approximately 14% was recorded for iGAS disease in the total of all studies' neonates. (4) Conclusions: Although iGAS is a rare entity of neonatal infections, the potential severity of the disease and the rapid deterioration requires the development of quick analysis methods for the detection of GAS allowing the prompt diagnosis and administration of the indicated antibiotic treatment. Furthermore, given the exceptional risk for both the pregnant woman and the neonate, it is very important to raise awareness and create easily accessible guidelines that could facilitate the prevention and management of maternal as well as the subsequent neonatal severe iGAS disease.
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Affiliation(s)
- Rozeta Sokou
- Neonatal Intensive Care Unit, “Agios Panteleimon” General Hospital of Nikea, 18454 Piraeus, Greece; (E.-D.B.); (A.K.)
- Neonatal Department, National and Kapodistrian University of Athens, Aretaieio Hospital, 11528 Athens, Greece; (F.F.); (V.D.); (Z.I.); (T.B.); (N.I.)
| | - Filippos Filippatos
- Neonatal Department, National and Kapodistrian University of Athens, Aretaieio Hospital, 11528 Athens, Greece; (F.F.); (V.D.); (Z.I.); (T.B.); (N.I.)
| | - Vasiliki Daniil
- Neonatal Department, National and Kapodistrian University of Athens, Aretaieio Hospital, 11528 Athens, Greece; (F.F.); (V.D.); (Z.I.); (T.B.); (N.I.)
| | - Efstathia-Danai Bikouli
- Neonatal Intensive Care Unit, “Agios Panteleimon” General Hospital of Nikea, 18454 Piraeus, Greece; (E.-D.B.); (A.K.)
| | - Andreas G. Tsantes
- Microbiology Department, “Saint Savvas” Oncology Hospital, 11522 Athens, Greece;
| | - Daniele Piovani
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy; (D.P.); (S.B.)
- IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Stefanos Bonovas
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy; (D.P.); (S.B.)
- IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Zoi Iliodromiti
- Neonatal Department, National and Kapodistrian University of Athens, Aretaieio Hospital, 11528 Athens, Greece; (F.F.); (V.D.); (Z.I.); (T.B.); (N.I.)
| | - Theodora Boutsikou
- Neonatal Department, National and Kapodistrian University of Athens, Aretaieio Hospital, 11528 Athens, Greece; (F.F.); (V.D.); (Z.I.); (T.B.); (N.I.)
| | - Argirios E. Tsantes
- Laboratory of Haematology and Blood Bank Unit, “Attiko” Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece;
| | - Nicoletta Iacovidou
- Neonatal Department, National and Kapodistrian University of Athens, Aretaieio Hospital, 11528 Athens, Greece; (F.F.); (V.D.); (Z.I.); (T.B.); (N.I.)
| | - Aikaterini Konstantinidi
- Neonatal Intensive Care Unit, “Agios Panteleimon” General Hospital of Nikea, 18454 Piraeus, Greece; (E.-D.B.); (A.K.)
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15
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Achong C, Chowdhury T, Mustafa F, Smith D, Moussouris H. Streptococcal Bacteremia and Toxic Shock Syndrome: A Rare Etiology Requiring Prompt Diagnosis. Cureus 2023; 15:e43944. [PMID: 37746417 PMCID: PMC10516451 DOI: 10.7759/cureus.43944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2023] [Indexed: 09/26/2023] Open
Abstract
Bullous impetigo leading to streptococcal toxic shock syndrome (STSS) immune activation and massive cytokine release is a rare condition. It has a significant mortality rate, which calls for quick diagnosis, early suspicion, and integrated treatment. Herein, we discuss the case of a 66-year-old man who underwent evaluation for leg swelling before quickly going into shock and experiencing respiratory failure, which necessitated invasive mechanical intubation. Streptococcus pyogenes was identified by blood culture, and STSS was identified. Recommended antibiotics, intravenous (IV) immunoglobulin, and fluids made up the treatment regimen. In this case, the streptococcal infection deteriorated very quickly, and there was a rare relationship with bullous impetigo, which led to shock and respiratory failure. This case sheds lights on the need of having an early suspicion of this syndrome when a diabetic patient develops a skin lesion. A prompt diagnosis is necessary.
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Affiliation(s)
| | | | | | - David Smith
- Intensive Care Unit, One Brooklyn Health, New York, USA
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16
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Nagira K, Ogoshi T, Akahori K, Enokida S, Enokida M, Ueda T, Homma M, Nagashima H. Factors associated with mortality in patients with extremity necrotizing soft-tissue infections: a single academic center experience. Langenbecks Arch Surg 2023; 408:189. [PMID: 37166568 DOI: 10.1007/s00423-023-02929-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 05/04/2023] [Indexed: 05/12/2023]
Abstract
PURPOSE Necrotizing soft-tissue infection (NSTI) is a surgical emergency associated with high mortality. This study primarily aimed to identify the factors associated with in-hospital mortality due to NSTI in the extremities at a single institution. Secondarily, we aimed to clarify the effectiveness of the optimal combination of hyperbaric oxygen therapy (HBOT) and surgery for NSTI treatment. STUDY DESIGN Retrospective observational study. METHODS This study included all patients newly diagnosed with NSTI in the extremity from 2003 to 2021 in our hospital. Factors associated with mortality, including patient's characteristics, duration from onset to hospitalization, NSTI type, and clinical data at the initial visit; acute disseminated intravascular coagulation (DIC), laboratory risk indicator for necrotizing fasciitis score, and sequential organ failure assessment score; treatment, initial surgery, surgery times, amputation, HBOT, combined surgery with HBOT, and clinical outcomes; amputation rate, mortality rate, and hospitalization duration were examined. RESULTS A total of 37 cases were treated for NSTIs. The median age was 64 years (range: 22-86). Five cases (13.5%) died during hospitalization. Ten patients were diagnosed with DIC at the initial visit, of whom four died. HBOT combined with surgery was performed in 23 cases, and 16 cases underwent multiple surgeries. Factors associated with mortality included DIC (p = 0.015, 95% confidence interval [CI]: 0.015-0.633) and multiple surgeries combined with HBOT (p = 0.028, 95% CI: 1.302-95.418). CONCLUSION This study demonstrates that DIC at the initial visit is associated with mortality in extremity NSTI. Additionally, HBOT might improve prognosis when combined with multiple surgeries.
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Affiliation(s)
- Keita Nagira
- Department of Orthopedic Surgery, Faculty of Medicine, Tottori University, 36-1 Nishi-Cho, Yonago, Tottori, 683-8504, Japan.
| | - Tomofumi Ogoshi
- Department of Emergency and Disaster Medicine, Tottori University, Tottori, Japan
| | - Keiichi Akahori
- Department of Orthopedic Surgery, Faculty of Medicine, Tottori University, 36-1 Nishi-Cho, Yonago, Tottori, 683-8504, Japan
| | - Shinpei Enokida
- Department of Orthopedic Surgery, Faculty of Medicine, Tottori University, 36-1 Nishi-Cho, Yonago, Tottori, 683-8504, Japan
| | - Makoto Enokida
- Department of Orthopedic Surgery, Faculty of Medicine, Tottori University, 36-1 Nishi-Cho, Yonago, Tottori, 683-8504, Japan
| | - Takahiro Ueda
- Department of Emergency and Disaster Medicine, Tottori University, Tottori, Japan
| | - Masato Homma
- Department of Emergency and Disaster Medicine, Tottori University, Tottori, Japan
| | - Hideki Nagashima
- Department of Orthopedic Surgery, Faculty of Medicine, Tottori University, 36-1 Nishi-Cho, Yonago, Tottori, 683-8504, Japan
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17
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Schlievert P, Kilgore S, Leung D. Agr Regulation of Streptococcal Pyrogenic Exotoxin A in Staphylococcus aureus. MICROPUBLICATION BIOLOGY 2023; 2023:10.17912/micropub.biology.000795. [PMID: 37179971 PMCID: PMC10167548 DOI: 10.17912/micropub.biology.000795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Figures] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 04/22/2023] [Accepted: 04/21/2023] [Indexed: 05/15/2023]
Abstract
Group A streptococcal pyrogenic exotoxins (SPEs A, B, and C) are superantigens. SPE A shares high sequence similarity with Staphylococcus aureus enterotoxins (SEs) B and C. Since SPE A is bacteriophage-encoded, we hypothesized that its gene ( speA ) was acquired from S. aureus . speA , when cloned into S. aureus , was stably expressed, its protein resistant to proteases, and the gene under accessory gene regulator control. speA was acquired by streptococci from cross-species transduction. speB was not expressed in S. aureus. SPE C was degraded by staphylococcal proteases. The genes speB and speC were not recently acquired from S. aureus.
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18
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Kourti A, Mentesidou L, Michalopoulou A, Maritsi D, Bachou T. Antiphospholipid syndrome after streptococcal toxic shock syndrome later diagnosed as Behcet's disease. Blood Coagul Fibrinolysis 2023; 34:221-223. [PMID: 36728696 DOI: 10.1097/mbc.0000000000001189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Streptococcal toxic shock syndrome is a severe complication of group A streptococci. The production of antiphospholipid antibodies has been associated with streptococcal infections and with autoimmune diseases. Furthermore, streptococcal infections could be a trigger of Behcet's disease. We report a case of a boy who presented antiphospholipid syndrome after streptococcal toxic shock syndrome later he was diagnosed with Behcet's disease.
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Affiliation(s)
- Afroditi Kourti
- 3rd Department of Pediatrics of University of Athens, "Attikon" University General Hospital
| | - Lida Mentesidou
- 1st Department of Pediatrics, 'Panagiotis and Aglaia Kyriakou' Children's Hospital
| | | | - Despoina Maritsi
- 2nd Department of Pediatrics of University of Athens, Panagiotis and Aglaia Kyriakou Children's Hospital, Athens Greece
| | - Theodora Bachou
- 1st Department of Pediatrics, 'Panagiotis and Aglaia Kyriakou' Children's Hospital
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19
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Pomputius WF, Kilgore SH, Schlievert PM. Probable enterotoxin-associated toxic shock syndrome caused by Staphylococcus epidermidis. BMC Pediatr 2023; 23:108. [PMID: 36882717 PMCID: PMC9989563 DOI: 10.1186/s12887-023-03914-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 02/17/2023] [Indexed: 03/09/2023] Open
Abstract
BACKGROUND We describe a case of a toxic shock-like syndrome in a child, which was associated with Staphylococcus epidermidis instead of Staphylococcus aureus or Streptococcus pyogenes, the usual causes of toxic shock syndrome. CASE PRESENTATION The patient was an 8-year-old boy who developed a toxic shock syndrome-like illness, including fever, hypotension, and rash. The Staphylococcus epidermidis isolate was cultured from urine, but this organism was unavailable for toxin testing. Multiple blood cultures were negative. Instead, a highly novel assay was used on acute plasma from the patient which demonstrated the presence of the genes for superantigens, staphylococcal enterotoxins A, C, D, and E. Superantigens are the known causes of toxic shock syndrome. CONCLUSIONS Our study suggests strongly that Staphylococcus epidermidis was causing the TSS symptoms through the known Staphylococcus aureus superantigens. It is unknown how many other such patients exist; this should be explored. Of great importance is that PCR performed directly on blood plasma in the absence of microbial isolation could be used to demonstrate superantigen genes.
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Affiliation(s)
- William F Pomputius
- Division of Infectious Disease, Children's Minnesota, Minneapolis, MN, 55455, USA
| | - Samuel H Kilgore
- Department of Microbiology and Immunology, Carver College of Medicine, University of Iowa, 51 Newton Road, Iowa City, Iowa, 52242, USA
| | - Patrick M Schlievert
- Department of Microbiology and Immunology, Carver College of Medicine, University of Iowa, 51 Newton Road, Iowa City, Iowa, 52242, USA. .,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, 52242, USA.
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20
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Breidung D, Malsagova AT, Barth AA, Megas IF, Billner M, Hitzl W, Reichert B. Diagnostic and prognostic value of the Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) based on an 18 years' experience. J Plast Reconstr Aesthet Surg 2023; 77:228-235. [PMID: 36587478 DOI: 10.1016/j.bjps.2022.11.061] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 09/30/2022] [Accepted: 11/29/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND Necrotising fasciitis (NF) represents a rare but often life-threatening condition. Early diagnosis and surgical treatment are of vital importance. The LRINEC score was developed to distinguish necrotising fasciitis from other soft tissue infections (STI) at initial evaluation using six laboratory values. In this retrospective study, we attempted to determine the diagnostic and prognostic value of the LRINEC score. METHODS A total of 125 patients, hospitalised in our clinic between 2003 and 2021 with a histologically confirmed diagnosis of necrotising fasciitis (NF group) and 319 patients with surgically treated soft tissue infections (STI group) were included in this study. Individual LRINEC scores were calculated and analysed retrospectively. RESULTS The sensitivity of the LRINEC score at the cut-off point of ≥ 6 was 59%, whereas the specificity was 82%. The positive and negative predictive values were 57% and 84%, respectively. The mean LRINEC score was significantly higher in the NF group than in the STI group (6.0 compared to 2.4, respectively). All clinical outcome parameters such as amputation and mortality rates (15% vs 1%) were found to be significantly higher in the NF group (p<0.001). Within the NF group, there was no statistically significant association between the LRINEC score and clinical outcomes except for the necessary number of operations. CONCLUSION In isolation, we found the LRINEC score not to be a reliable enough diagnostic tool for the differentiation between NF and other soft tissue infections, because of its low sensitivity. Although we cannot recommend it as a prognostic tool either, we do believe it can be a useful adjunct to the clinical suspicion of NF.
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Affiliation(s)
- David Breidung
- Department of Plastic, Reconstructive and Hand Surgery, Burn Center for Severe Burn Injuries, Klinikum Nuremberg Hospital, Paracelsus Medical University, Breslauer Str. 201, 90471 Nuremberg/Prof.-Ernst-Nathan Straße 1, 90419 Nuremberg, Germany.
| | - Asja T Malsagova
- Department of Plastic, Reconstructive and Hand Surgery, Burn Center for Severe Burn Injuries, Klinikum Nuremberg Hospital, Paracelsus Medical University, Breslauer Str. 201, 90471 Nuremberg/Prof.-Ernst-Nathan Straße 1, 90419 Nuremberg, Germany
| | - Andrè A Barth
- Department of Plastic, Reconstructive and Hand Surgery, Burn Center for Severe Burn Injuries, Klinikum Nuremberg Hospital, Paracelsus Medical University, Breslauer Str. 201, 90471 Nuremberg/Prof.-Ernst-Nathan Straße 1, 90419 Nuremberg, Germany
| | - Ioannis-Fivos Megas
- Department of Plastic, Reconstructive and Hand Surgery, Burn Center for Severe Burn Injuries, Klinikum Nuremberg Hospital, Paracelsus Medical University, Breslauer Str. 201, 90471 Nuremberg/Prof.-Ernst-Nathan Straße 1, 90419 Nuremberg, Germany
| | - Moritz Billner
- Department of Plastic, Reconstructive and Hand Surgery, Burn Center for Severe Burn Injuries, Klinikum Nuremberg Hospital, Paracelsus Medical University, Breslauer Str. 201, 90471 Nuremberg/Prof.-Ernst-Nathan Straße 1, 90419 Nuremberg, Germany
| | - Wolfgang Hitzl
- Research and Innovation Management (RIM), Paracelsus Medical University Salzburg, Department of Ophthalmology and Optometry, Salzburg, Austria; Department of Ophthalmology and Optometry, Paracelsus Medical University Salzburg, Muellner Hauptstr. 48, 5020, Salzburg, Austria; Research Program Experimental Ophthalmology and Glaucoma Research, Paracelsus Medical University, Muellner Hauptstrasse 48, 5020, Salzburg, Austria
| | - Bert Reichert
- Department of Plastic, Reconstructive and Hand Surgery, Burn Center for Severe Burn Injuries, Klinikum Nuremberg Hospital, Paracelsus Medical University, Breslauer Str. 201, 90471 Nuremberg/Prof.-Ernst-Nathan Straße 1, 90419 Nuremberg, Germany
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21
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Nakai K, Mihara Y, Kado H, Hosokawa Y, Hatta T. Hemodialysis Patient with Streptococcal Toxic Shock Syndrome and Penile Necrosis. Intern Med 2023; 62:135-138. [PMID: 35650128 PMCID: PMC9876726 DOI: 10.2169/internalmedicine.9467-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
A 72-year-old man on hemodialysis due to diabetic nephropathy presented with a fever and penile pain. Although his physical examination was unremarkable, his general condition deteriorated. Penile necrosis was observed by evening on the same day of presentation, and the patient died the next morning. Blood cultures revealed the presence of Group G Streptococcus, leading to a diagnosis of streptococcal toxic shock syndrome (STSS). Autopsy suggested penile necrosis due to septic shock. STSS in hemodialysis patients with vascular calcification, even in the absence of calciphylaxis, can lead to severe organ damage due to ischemia.
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Affiliation(s)
- Kunihiro Nakai
- Department of Nephrology, Omihachiman Community Medical Center, Japan
| | - Yu Mihara
- Department of Nephrology, Omihachiman Community Medical Center, Japan
| | - Hiroshi Kado
- Department of Nephrology, Omihachiman Community Medical Center, Japan
| | - Yohei Hosokawa
- Department of Pathology, Omihachiman Community Medical Center, Japan
| | - Tsuguru Hatta
- Department of Nephrology, Omihachiman Community Medical Center, Japan
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22
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Kurachi A, Ishida Y, Nakazawa K, Okada T, Kishida T, Uchino H. Necrotizing fasciitis and septic shock due to streptococcal toxic shock syndrome in an elderly patient: A case report. Clin Case Rep 2023; 11:e6846. [PMID: 36698511 PMCID: PMC9850853 DOI: 10.1002/ccr3.6846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 12/28/2022] [Accepted: 12/30/2022] [Indexed: 01/20/2023] Open
Abstract
Streptococcal toxic shock syndrome (STSS) has a high mortality rate, and most patients die within a few days of onset. We report an elderly patient with STSS, necrotizing fasciitis and septic shock caused by group G streptococcus who was successfully treated with multidisciplinary therapy.
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Affiliation(s)
- Akiko Kurachi
- Department of AnesthesiologyTokyo Medical UniversityTokyoJapan
| | - Yusuke Ishida
- Department of AnesthesiologyTokyo Medical UniversityTokyoJapan
| | - Koichi Nakazawa
- Department of AnesthesiologyTokyo Medical UniversityTokyoJapan
| | - Toshio Okada
- Department of AnesthesiologyTokyo Medical UniversityTokyoJapan
| | - Takumi Kishida
- Department of AnesthesiologyTokyo Medical UniversityTokyoJapan
| | - Hiroyuki Uchino
- Department of AnesthesiologyTokyo Medical UniversityTokyoJapan
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ICU Management of Invasive β-Hemolytic Streptococcal Infections. Infect Dis Clin North Am 2022; 36:861-887. [DOI: 10.1016/j.idc.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Bartoszko JJ, Elias Z, Rudziak P, Lo CKL, Thabane L, Mertz D, Loeb M. Prognostic factors for streptococcal toxic shock syndrome: systematic review and meta-analysis. BMJ Open 2022; 12:e063023. [PMID: 36456018 PMCID: PMC9716873 DOI: 10.1136/bmjopen-2022-063023] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVES To quantify the prognostic effects of demographic and modifiable factors in streptococcal toxic shock syndrome (STSS). DESIGN Systematic review and meta-analysis. DATA SOURCES MEDLINE, EMBASE and CINAHL from inception to 19 September 2022, along with citations of included studies. ELIGIBILITY CRITERIA Pairs of reviewers independently screened potentially eligible studies of patients with Group A Streptococcus-induced STSS that quantified the association between at least one prognostic factor and outcome of interest. DATA EXTRACTION AND SYNTHESIS We performed random-effects meta-analysis after duplicate data extraction and risk of bias assessments. We rated the certainty of evidence using the Grading of Recommendations, Assessment, Development and Evaluation approach. RESULTS One randomised trial and 40 observational studies were eligible (n=1918 patients). We found a statistically significant association between clindamycin treatment and mortality (n=144; OR 0.14, 95% CI 0.06 to 0.37), but the certainty of evidence was low. Within clindamycin-treated STSS patients, we found a statistically significant association between intravenous Ig treatment and mortality (n=188; OR 0.34, 95% CI 0.15 to 0.75), but the certainty of evidence was also low. The odds of mortality may increase in patients ≥65 years when compared with patients 18-64 years (n=396; OR 2.37, 95% CI 1.47 to 3.84), but the certainty of evidence was low. We are uncertain whether non-steroidal anti-inflammatory drugs increase the odds of mortality (n=50; OR 4.14, 95% CI 1.13 to 15.14; very low certainty). Results failed to show a significant association between any other prognostic factor and outcome combination (very low to low certainty evidence) and no studies quantified the association between a prognostic factor and morbidity post-infection in STSS survivors. CONCLUSIONS Treatment with clindamycin and within clindamycin-treated patients, IVIG, was each significantly associated with mortality, but the certainty of evidence was low. Future research should focus on morbidity post-infection in STSS survivors. PROSPERO REGISTRATION NUMBER CRD42020166961.
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Affiliation(s)
- Jessica J Bartoszko
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Zeyad Elias
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Paulina Rudziak
- Department of Biology, Western University, London, Ontario, Canada
| | - Carson K L Lo
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Departments of Anesthesia and Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Dominik Mertz
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Mark Loeb
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
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Matsuda N, Ishikawa K, Funayama E, Mitamura S, Sasaki S, Yamamoto Y, Maeda T. Streptococcal Toxic Shock Syndrome in a Pediatric Patient With Intramuscular Venous Malformation in the Neck. J Emerg Med 2022; 63:e72-e76. [DOI: 10.1016/j.jemermed.2022.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 06/10/2022] [Accepted: 07/09/2022] [Indexed: 11/07/2022]
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Murata S, Toyoshima C, Suzuki S, Sato N. Suggested organism entry portal of necrotizing fasciitis with complete DNA from fascia, blood, and pharyngeal ulcers: A case report. Ann Med Surg (Lond) 2022; 82:104732. [PMID: 36268407 PMCID: PMC9577831 DOI: 10.1016/j.amsu.2022.104732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 09/12/2022] [Accepted: 09/18/2022] [Indexed: 12/05/2022] Open
Abstract
Introduction and importance In approximately 50% of patients with necrotizing fasciitis, infection begins deep in the soft tissues. A history of trauma is often absent. The mechanism of spread has not been elucidated. We report a case of type II necrotizing fasciitis in which the streptococcal strain was identical to isolates from other locations in the same patient. Case presentation A 42-year-old man presented with left leg pain. Two days prior, he had a non-penetrating injury to the left thigh while playing futsal. Workup revealed swelling of the left gastrocnemius. He was admitted to orthopaedics. On the third hospital day, he was referred to our department for hypotension, impending respiratory failure, and decreased sensorium, and subsequently admitted to the ICU. A biopsy was done on the left gastrocnemius fascia. He was diagnosed with necrotizing fasciitis. On the seventh hospital day, left hip amputation and extensive debridement of the trunk were done. Patient improved and eventually recovered. Clinical discussion Group A streptococcus was isolated in from the fascia, blood, and pharyngeal ulcer. Pulsed field gel electrophoresis showed all isolates to be genetically identical. An oral route of infection was considered. Conclusions This is the first report in which etiologic agent of necrotizing fasciitis is genetically identical with isolates from other parts in the absence of trauma. Point of entry for bacteria occurs after a non-penetrating injury is unknown. The same strain from the fascia was isolated from blood, and a pharyngeal ulcer. This is the first report of entry portal for necrotizing fasciitis via the mouth.
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Affiliation(s)
- Satoru Murata
- Department of Emergency Medicine and Critical Care Medicine, Ehime University Graduate School of Medicine, Japan
- Department of Emergency Medicine and Intensive Care Medicine, Saiseikai Noe Hospital, Japan
- Corresponding author. Ehime University Graduate school of Medicine, Department of Emergency and Critical Care Medicine, 454 Shitsukawa, Toon City, Ehime Prefecture, 791-0295, Japan.
| | - Chie Toyoshima
- Department of Emergency Medicine and Intensive Care Medicine, Saiseikai Noe Hospital, Japan
| | - Satoshi Suzuki
- Department of Emergency Medicine and Intensive Care Medicine, Saiseikai Noe Hospital, Japan
| | - Norio Sato
- Department of Emergency Medicine and Critical Care Medicine, Ehime University Graduate School of Medicine, Japan
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Household Transmission of Group A Streptococcus Necrotizing Fasciitis. J Am Acad Orthop Surg Glob Res Rev 2022; 6:01979360-202208000-00001. [PMID: 35930803 PMCID: PMC9351906 DOI: 10.5435/jaaosglobal-d-21-00171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 06/07/2022] [Indexed: 11/22/2022]
Abstract
A healthy 40-year-old woman was diagnosed with necrotizing fasciitis 2 days after her husband's death from the same infectious process. Prompt identification and immediate surgical intervention prevented a similar result in this patient. Additional investigation into both patients' medical records found the inciting organism to be group A streptococcus. Although the exact mechanism of inoculation is unknown, the spread of this infection within a household prompts the question of whether antibiotic prophylaxis should be given among close contacts in future cases of necrotizing fasciitis.
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Streptococcus pyogenes NAD+-Glycohydrolase Reduces Skeletal Muscle βNAD+ Levels Independently of Streptolysin O. Microorganisms 2022; 10:microorganisms10071476. [PMID: 35889195 PMCID: PMC9322677 DOI: 10.3390/microorganisms10071476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/14/2022] [Accepted: 07/16/2022] [Indexed: 12/03/2022] Open
Abstract
Necrotizing soft tissue infections caused by Streptococcus pyogenes (group A streptococcus [GAS]) are characterized by rapid and extensive necrosis of fascia and muscle. Molecular epidemiological studies have demonstrated a positive correlation between GAS isolates that cause invasive infections and the production of S. pyogenes NAD+-glycohydrolase (SPN), an NADase secreted by GAS, but the effect of SPN on muscle cells has not been described. Thus, using standard βNAD+ and ATP quantification assays, we investigated the effects of SPN on cultured human skeletal muscle cell (SkMC) βNAD+ and ATP with and without streptolysin O (SLO)–a secreted cholesterol-dependent cytolysin known to act synergistically with SPN. We found that culture supernatants from GAS strains producing SLO and SPN depleted intracellular βNAD+ and ATP, while exotoxins from a GAS strain producing SLO and an enzymatically-inactive form of SPN had no effect on βNAD+ or ATP. Addition of purified, enzymatically-active SPN to NADase-negative culture supernatants or sterile media reconstituted βNAD+ depletion but had no effect ATP levels. Further, SPN-mediated βNAD+ depletion could be augmented by SLO or the homologous cholesterol-dependent cytolysin, perfringolysin O (PFO). Remarkably, SPN-mediated βNAD+ depletion was SkMC-specific, as purified SPN had minimal effect on epithelial cell βNAD+. Taken together, this study identifies a previously unrecognized role for SPN as a major disruptor of skeletal muscle βNAD+. Such activity could contribute to the rapid and widespread myonecrosis characteristic of severe GAS soft tissue infections.
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Shin H, Takahashi T, Lee S, Choi EH, Maeda T, Fukushima Y, Kim S. Comparing Genomic Characteristics of Streptococcus pyogenes Associated with Invasiveness over a 20-year Period in Korea. Ann Lab Med 2022; 42:438-446. [PMID: 35177564 PMCID: PMC8859563 DOI: 10.3343/alm.2022.42.4.438] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 07/23/2021] [Accepted: 12/06/2021] [Indexed: 11/29/2022] Open
Abstract
Background Few studies have investigated the invasiveness of Streptococcus pyogenes based on whole-genome sequencing (WGS). Using WGS, we determined the genomic features associated with invasiveness of S. pyogenes strains in Korea. Methods Forty-five S. pyogenes strains from 1997, 2006, and 2017, including common emm types, were selected from the repository at Gyeongsang National University Hospital in Korea. In addition, 48 S. pyogenes strains were randomly selected depending on their invasiveness between 1997 and 2017 to evaluate the genetic evolution and the associations between invasiveness and genetic profiles. Using WGS datasets, we conducted virulence-associated DNA sequence determination, emm genotyping, multi-locus sequence typing (MLST), and superantigen gene profiling. Results In total, 87 strains were included in this study. There were no significant differences in the genomic features throughout the study periods. Four genes, csn1, ispE, nisK, and citC, were detected only in invasive strains. There was a significant association between invasiveness and emm cluster type A-C3, including, emm1.0, emm1.18, emm1.3, and emm1.76 (P<0.05). The predominant emm1 lineage belonged to ST28. There were no associations between invasiveness and superantigen gene profiles. Conclusions This is the first study using WGS datasets of S. pyogenes strains collected between 1997 and 2017 in Korea. Streptococcal invasiveness is associated with the presence of csn1, ispE, nisK, and citC. The emm1 lineage and ST28 clone are explicitly associated with invasiveness, whereas genomic features remained stable over the 20-year period.
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Affiliation(s)
- Hyoshim Shin
- Department of Laboratory Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Takashi Takahashi
- Laboratory of Infectious Diseases, Graduate School of Infection Control Sciences & Ōmura Satoshi Memorial Institute, Kitasato University, Tokyo, Japan
| | - Seungjun Lee
- Department of Laboratory Medicine, Gyeongsang National University Changwon Hospital, Changwon, Korea
| | - Eun Hwa Choi
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Takahiro Maeda
- Laboratory of Infectious Diseases, Graduate School of Infection Control Sciences & Ōmura Satoshi Memorial Institute, Kitasato University, Tokyo, Japan
| | - Yasuto Fukushima
- Laboratory of Infectious Diseases, Graduate School of Infection Control Sciences & Ōmura Satoshi Memorial Institute, Kitasato University, Tokyo, Japan
| | - Sunjoo Kim
- Department of Laboratory Medicine, Gyeongsang National University Changwon Hospital, Changwon, Korea.,Department of Laboratory Medicine, Gyeongsang National University College of Medicine, Institute of Health Sciences, Jinju, Korea
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Wen S, Unuma K, Makino Y, Mori H, Uemura K. Fatal consequence after MiraDry® treatment: Necrotizing fasciitis complicated with streptococcal toxic shock syndrome. Leg Med (Tokyo) 2022; 58:102095. [PMID: 35662070 DOI: 10.1016/j.legalmed.2022.102095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 05/11/2022] [Accepted: 05/27/2022] [Indexed: 01/25/2023]
Abstract
MiraDry® is a microwave-based cosmetic device commonly used to treat hyperhidrosis and osmidrosis by affecting apocrine and eccrine sweat glands. In most countries, its application is limited to the axillary region. A healthy woman received MiraDry® treatment in the perineal, genital, and perianal regions for body odor in a cosmetic clinic. She experienced severe adverse effects after treatment, including persistent fever, sustained pain, and bleeding in the treated area. The condition deteriorated rapidly with systemic symptoms, and she died on the sixth day. Group A Streptococcus was detected in her skin in the treated areas, and in blood obtained in the hospital and during autopsy. Combined with the clinical diagnosis and autopsy findings, the woman's death was attributed to fatal necrotizing fasciitis (Fournier's gangrene) complicated by streptococcal toxic shock syndrome. Pathogen inoculation was most likely attributable to skin disruption caused by MiraDry® treatment. The MiraDry® application on the genital and perineum is occasionally performed by cosmetic surgeons; however, this case demonstrates the possibility of a rare but fatal complication. Therefore, this case report may be noteworthy and beneficial in forensic practice, and relevant in cosmetic clinical practice.
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Affiliation(s)
- Shuheng Wen
- Department of Forensic Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan
| | - Kana Unuma
- Department of Forensic Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan.
| | - Yohsuke Makino
- Department of Forensic Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
| | - Hiroki Mori
- Department of Plastic and Reconstructive Surgery, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan
| | - Koichi Uemura
- Department of Forensic Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan
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He W, Wu C, Zhong Y, Li J, Wang G, Yu B, Xu P, Xiao Y, Tang T. Case Report: Therapeutic Strategy With Delayed Debridement for Culture-Negative Invasive Group A Streptococcal Infections Diagnosed by Metagenomic Next-Generation Sequencing. Front Public Health 2022; 10:899077. [PMID: 35646803 PMCID: PMC9130855 DOI: 10.3389/fpubh.2022.899077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 04/19/2022] [Indexed: 11/13/2022] Open
Abstract
Streptococcal toxic shock syndrome (STSS) caused by group A streptococcus is a rare condition that rapidly developed to multiple organ failure even death. Therefore, prompt diagnosis, initiate appropriate antibiotics and other supportive treatments are critical. Here we reported a case of STSS caused by group A streptococcus infection. A healthy 39-year-old man presented a sudden pain in the left lower extremity, followed by a high fever (40.0 °C) with dizziness, nausea, and shortness of breath. Twenty-four hours before the visit, the patient showed anuria. The patient was then admitted to the intensive care unit. Blood examination revealed elevated levels of inflammatory markers and creatinine. He suffered from septic shock, dysfunction of coagulation, acute kidney dysfunction, acute respiratory distress syndrome, and acute liver function injury. The diagnosis was obtained through clinical manifestation and metagenomic next-generation sequencing (mNGS) drawn from the pustule and deep soft tissue (lower limb) samples while all bacterial cultures came back negative. The pustule mNGS report detected a total of 132 unique group A streptococcus sequence reads, representing 96.3% of microbial reads while the soft tissue mNGS report identified a total of 142474 unique group A streptococcus sequence reads, representing 100% of microbial reads. The patient was treated with aggressive fluid resuscitation, antibiotics comprising piperacillin/tazobactam and clindamycin, respiratory support, following the delayed surgical debridement. Intravenous immunoglobulin was also used for 5 days. On the 14th day after admission, he was transferred to the general ward for follow-up treatment. Our case highlighted, for the first time, the key role of mNGS in the early diagnosis of culture-negative invasive group A streptococcal infection. The case also suggested that clindamycin combined with beta-lactam antibiotics and adjunction of intravenous immunoglobulin therapy with delayed debridement performed well in the management of unstable STSS patients.
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Affiliation(s)
- Wenfang He
- Department of Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Chenfang Wu
- Department of Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Yanjun Zhong
- Department of Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Jinxiu Li
- Department of Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Guyi Wang
- Department of Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Bo Yu
- Department of Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Ping Xu
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
- Institute of Clinical Pharmacy, Central South University, Changsha, China
| | - Yiwen Xiao
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
- Institute of Clinical Pharmacy, Central South University, Changsha, China
| | - Tiantian Tang
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
- Institute of Clinical Pharmacy, Central South University, Changsha, China
- Hunan Provincial Engineering Research Centre of Translational Medicine and Innovative Drug, Changsha, China
- *Correspondence: Tiantian Tang
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Abu El Hawa AA, Dekker PK, Mishu MD, Kim KG, Mizher R, Fan KL, Attinger CE, Evans KK. Early Diagnosis and Surgical Management of Necrotizing Fasciitis of the Lower Extremities: Risk Factors for Mortality and Amputation. Adv Wound Care (New Rochelle) 2022; 11:217-225. [PMID: 34297612 DOI: 10.1089/wound.2021.0031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objective: In this study, we seek to identify patient characteristics associated with limb loss and mortality while exploring the potential impact a multidisciplinary care team may have. Approach: This was a 10-year retrospective review of patients presenting to our tertiary care center for limb salvage with a diagnosis of lower extremity (LE) necrotizing fasciitis (NF). Patient demographics, clinical history, and outcomes were compared between survivors and nonsurvivors and between those who underwent LE amputation and those who did not. The article adheres to the strengthening the reporting of observational studies in epidemiology statement. Results: Sixty-two patients presented to our tertiary care center for limb salvage with LE NF. Forty-two patients underwent LE amputation: 27 (43.5%) underwent below-knee amputation, 1 (1.6%) underwent above-knee amputation, 8 (12.9%) underwent transmetatarsal amputation and 2 (3.2%) underwent calcanectomy. The overall mortality rate was 16.1% (n = 10). Risk factors for mortality included increased age (p = 0.034), higher Charlson Comorbidity Index (p = 0.011), thrombocytopenia (p = 0.002), hypotension (p = 0.015), erythema (p = 0.010), pain (p = 0.027), diabetes mellitus (p = 0.012), and malignancy (p < 0.001). Risk factors for LE amputation included DM (p = 0.017), peripheral vascular disease (p = 0.033), and an elevated laboratory risk indicator for necrotizing fasciitis (LRINC) (p = 0.033). Innovation: To identify outcomes after admission to a tertiary hospital with a dedicated limb salvage team with LE NF and to analyze risk factors for mortality and amputation. Conclusions: This is a comprehensive analysis of risk factors for mortality and amputation after LE NF. Our institution's experience highlights the importance of a multidisciplinary approach in the care of these patients.
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Affiliation(s)
| | - Paige K. Dekker
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Mark D. Mishu
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Kevin G. Kim
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Rami Mizher
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Kenneth L. Fan
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Christopher E. Attinger
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Karen K. Evans
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
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Schlievert PM, Kilgore SH, Benavides A, Klingelhutz AJ. Pathogen Stimulation of Interleukin-8 from Human Vaginal Epithelial Cells through CD40. Microbiol Spectr 2022; 10:e0010622. [PMID: 35297656 PMCID: PMC9045207 DOI: 10.1128/spectrum.00106-22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 03/08/2022] [Indexed: 01/08/2023] Open
Abstract
Many bacterial and fungal pathogens cause disease across mucosal surfaces, and to a lesser extent through skin surfaces. Pathogens that potentially cause disease vaginally across epithelial cells include Staphylococcus aureus, group A and B streptococci, Escherichia coli, Neisseria gonorrhoeae, and Candida albicans. We have previously shown that staphylococcal and streptococcal superantigens induce inflammatory chemokines from vaginal epithelial cells through the immune costimulatory molecule CD40 through use of a CRISPR cas9 knockout mutant and complemented epithelial cell line. In this study, we show that the potential vaginal pathogens S. aureus, group A and B streptococci, E. coli, an Enterococcus faecalis strain, and C. albicans in part use CD40 to stimulate interleukin-8 (IL-8) production from human vaginal epithelial cells. In contrast, N. gonorrhoeae does not appear to use CD40 to signal IL-8 production. Normal flora Lactobacillus crispatus and an Enterococcus faecalis strain that produces reutericyclin do not induce IL-8. These data indicate that many potential pathogens, but no normal commensals, induce IL-8 to help disrupt the human vaginal epithelial barrier through CD40, thus providing a potential therapeutic target for drug development. IMPORTANCE Most bacterial and fungal pathogens cause disease across mucosal, and to a lesser extent, skin barriers with the help of induced chemokines from epithelial cells. In this study, we showed that potential vaginal pathogens Staphylococcus aureus, group A and B streptococci, some Enterococcus faecalis strains, Escherichia coli, and Candida albicans use the immune costimulatory molecule CD40 to induce the chemokine interleukin-8 production. In contrast, Neisseria gonorrhoeae does not use CD40 to stimulate interleukin-8. Normal flora lactobacilli and at least one E. faecalis strain do not induce interleukin-8.
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Affiliation(s)
- Patrick M. Schlievert
- Department of Microbiology and Immunology, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Samuel H. Kilgore
- Department of Microbiology and Immunology, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Andrea Benavides
- Department of Microbiology and Immunology, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Aloysius J. Klingelhutz
- Department of Microbiology and Immunology, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
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Modeling the effects of air pollution and meteorological factors on scarlet fever in five provinces, Northwest China, 2013-2018. J Theor Biol 2022; 544:111134. [DOI: 10.1016/j.jtbi.2022.111134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 04/06/2022] [Accepted: 04/11/2022] [Indexed: 11/23/2022]
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Siggins MK, Sriskandan S. Bacterial Lymphatic Metastasis in Infection and Immunity. Cells 2021; 11:33. [PMID: 35011595 PMCID: PMC8750085 DOI: 10.3390/cells11010033] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 12/09/2021] [Accepted: 12/16/2021] [Indexed: 12/12/2022] Open
Abstract
Lymphatic vessels permeate tissues around the body, returning fluid from interstitial spaces back to the blood after passage through the lymph nodes, which are important sites for adaptive responses to all types of pathogens. Involvement of the lymphatics in the pathogenesis of bacterial infections is not well studied. Despite offering an obvious conduit for pathogen spread, the lymphatic system has long been regarded to bar the onward progression of most bacteria. There is little direct data on live virulent bacteria, instead understanding is largely inferred from studies investigating immune responses to viruses or antigens in lymph nodes. Recently, we have demonstrated that extracellular bacterial lymphatic metastasis of virulent strains of Streptococcus pyogenes drives systemic infection. Accordingly, it is timely to reconsider the role of lymph nodes as absolute barriers to bacterial dissemination in the lymphatics. Here, we summarise the routes and mechanisms by which an increasing variety of bacteria are acknowledged to transit through the lymphatic system, including those that do not necessarily require internalisation by host cells. We discuss the anatomy of the lymphatics and other factors that influence bacterial dissemination, as well as the consequences of underappreciated bacterial lymphatic metastasis on disease and immunity.
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Affiliation(s)
- Matthew K. Siggins
- National Heart and Lung Institute, Imperial College London, London W2 1PG, UK
- Department of Infectious Disease, Imperial College London, London W12 0NN, UK
| | - Shiranee Sriskandan
- Department of Infectious Disease, Imperial College London, London W12 0NN, UK
- MRC Centre for Molecular Bacteriology and Infection, Imperial College London, London SW7 2DD, UK
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Lee CY, Lee YJ, Chen CC, Kuo LJ. Streptococcal toxic shock syndrome after hemorrhoidectomy: A case report. World J Clin Cases 2021; 9:10238-10243. [PMID: 34904094 PMCID: PMC8638029 DOI: 10.12998/wjcc.v9.i33.10238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/22/2021] [Accepted: 10/14/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Streptococcal toxic-shock syndrome after hemorrhoidectomy is rare but may be catastrophic. Group A streptococci have produced various surface proteins and exotoxins due to genetic changes to fight the human body’s immune response. Though life threatening infection after hemorrhoidectomy rarely occurs, all surgeons should be aware of the potential complications of severe sepsis after hemorrhoidectomy and keep in mind their clinical presenting features in order to diagnose early and administer appropriate and effective therapeutic drugs early.
CASE SUMMARY Here, we present a case of a 56-year-old man with a painful thrombotic external hemorrhoid who presented to our outpatient department for management. There was no history of systemic diseases or recent disease infection. Hemorrhoidectomy was suggested and performed. After surgery, the patient developed hypotension, tachycardia, fever with chills and renal function impairment on day 2 post-operation. The clinical condition progressed to severe septic shock and metabolic acidosis. The patient responded poorly to treatment and expired after 1 d even with use of extracorporeal membrane oxygenation. The results of the blood and wound cultures showed group A streptococcus pyogenes.
CONCLUSION Although extremely uncommon, all surgeons should be aware of these potential life-threatening septic complications and alert to the presenting features for patients receiving hemorrhoidectomy.
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Affiliation(s)
- Chien-Yu Lee
- Department of Pediatrics, Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan 32748, Taiwan
| | - Yuarn-Jang Lee
- Division of Infectious Diseases, Department of Internal Medicine, Taipei Medical University Hospital, Taipei 11031, Taiwan
- Division of Infectious Diseases, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - Chia-Che Chen
- Division of Colorectal Surgery, Department of Surgery, Taipei Medical University Hospital, Taipei 11031, Taiwan
| | - Li-Jen Kuo
- Division of Colorectal Surgery, Department of Surgery, Taipei Medical University Hospital, Taipei 11031, Taiwan
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
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Johnson AF, LaRock CN. Antibiotic Treatment, Mechanisms for Failure, and Adjunctive Therapies for Infections by Group A Streptococcus. Front Microbiol 2021; 12:760255. [PMID: 34803985 PMCID: PMC8601407 DOI: 10.3389/fmicb.2021.760255] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 09/28/2021] [Indexed: 11/13/2022] Open
Abstract
Group A Streptococcus (GAS; Streptococcus pyogenes) is a nearly ubiquitous human pathogen responsible for a significant global disease burden. No vaccine exists, so antibiotics are essential for effective treatment. Despite a lower incidence of antimicrobial resistance than many pathogens, GAS is still a top 10 cause of death due to infections worldwide. The morbidity and mortality are primarily a consequence of the immune sequelae and invasive infections that are difficult to treat with antibiotics. GAS has remained susceptible to penicillin and other β-lactams, despite their widespread use for 80 years. However, the failure of treatment for invasive infections with penicillin has been consistently reported since the introduction of antibiotics, and strains with reduced susceptibility to β-lactams have emerged. Furthermore, isolates responsible for outbreaks of severe infections are increasingly resistant to other antibiotics of choice, such as clindamycin and macrolides. This review focuses on the challenges in the treatment of GAS infection, the mechanisms that contribute to antibiotic failure, and adjunctive therapeutics. Further understanding of these processes will be necessary for improving the treatment of high-risk GAS infections and surveillance for non-susceptible or resistant isolates. These insights will also help guide treatments against other leading pathogens for which conventional antibiotic strategies are increasingly failing.
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Affiliation(s)
- Anders F Johnson
- Microbiology and Molecular Genetics Program, Graduate Division of Biological and Biomedical Sciences, Laney Graduate School, Emory University, Atlanta, GA, United States
| | - Christopher N LaRock
- Microbiology and Molecular Genetics Program, Graduate Division of Biological and Biomedical Sciences, Laney Graduate School, Emory University, Atlanta, GA, United States.,Department of Microbiology and Immunology, Emory University School of Medicine, Atlanta, GA, United States.,Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States.,Emory Antibiotic Resistance Center, Atlanta, GA, United States
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Matsuki J, Ishigami A, Tanaka M, Hata S, Ishida Y, Nosaka M, Kuninaka Y, Yamamoto H, Shimada E, Hashizume Y, Takayasu T, Kimura A, Furukawa F, Kondo T. A case of necrotizing fasciitis following intra-articular injections - Iatrogenic or spontaneous? Leg Med (Tokyo) 2021; 54:101989. [PMID: 34798589 DOI: 10.1016/j.legalmed.2021.101989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 10/25/2021] [Accepted: 11/05/2021] [Indexed: 10/19/2022]
Abstract
Here, we report a case of necrotizing fasciitis following intra-articular injection of hyaluronic acid. A 73-year-old female received intra-articular injections of hyaluronic acid due to arthralgia at the left shoulder and knee, and was found dead in her living room at one day. At the forensic autopsy, injection marks with bullae and erythema were found at the left shoulder and knee and liquefactive necrosis of muscle tissues was observed in the left but not right extremities. Histopathological examinations of the left upper arm and thigh revealed severe rhabdomyolysis with lots of bacterial clusters. Bacteriological examinations detected group A Streptococcus from intracardiac blood and affected muscle tissues. Postmortem biochemical analysis of blood showed escalated blood urea nitrogen (133.8 mg/dL), creatinine (4.57 mg/dL) and C-reactive protein (45.0 mg/dL). The cause of her death was diagnosed as streptococcal toxic shock syndrome (STSS). Moreover, it was suggested that the injection was inappropriately conducted and served as a portal of bacterial entry.
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Affiliation(s)
- Jumpei Matsuki
- Department of Forensic Medicine, Wakayama Medical University, 811-1 Kimiidera, 641-8509 Wakayama, Japan
| | - Akiko Ishigami
- Department of Forensic Medicine, Wakayama Medical University, 811-1 Kimiidera, 641-8509 Wakayama, Japan
| | - Motonari Tanaka
- Department of Forensic Medicine, Wakayama Medical University, 811-1 Kimiidera, 641-8509 Wakayama, Japan
| | - Satoshi Hata
- Department of Forensic Medicine, Wakayama Medical University, 811-1 Kimiidera, 641-8509 Wakayama, Japan
| | - Yuko Ishida
- Department of Forensic Medicine, Wakayama Medical University, 811-1 Kimiidera, 641-8509 Wakayama, Japan
| | - Mizuho Nosaka
- Department of Forensic Medicine, Wakayama Medical University, 811-1 Kimiidera, 641-8509 Wakayama, Japan
| | - Yumi Kuninaka
- Department of Forensic Medicine, Wakayama Medical University, 811-1 Kimiidera, 641-8509 Wakayama, Japan
| | - Hiroki Yamamoto
- Department of Forensic Medicine, Wakayama Medical University, 811-1 Kimiidera, 641-8509 Wakayama, Japan
| | - Emi Shimada
- Department of Forensic Medicine, Wakayama Medical University, 811-1 Kimiidera, 641-8509 Wakayama, Japan
| | - Yumiko Hashizume
- Department of Forensic Medicine, Wakayama Medical University, 811-1 Kimiidera, 641-8509 Wakayama, Japan
| | - Tatsunori Takayasu
- Department of Forensic Medicine, Wakayama Medical University, 811-1 Kimiidera, 641-8509 Wakayama, Japan
| | - Akihiko Kimura
- Department of Forensic Medicine, Wakayama Medical University, 811-1 Kimiidera, 641-8509 Wakayama, Japan
| | - Fukumi Furukawa
- Department of Forensic Medicine, Wakayama Medical University, 811-1 Kimiidera, 641-8509 Wakayama, Japan
| | - Toshikazu Kondo
- Department of Forensic Medicine, Wakayama Medical University, 811-1 Kimiidera, 641-8509 Wakayama, Japan.
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Yamaba Y, Takakuwa O, Ida C, Saito M, Kawae D, Yoshihara M, Kunii E, Imaeda K, Tatsuno I, Hasegawa T, Akita K. Streptococcal Toxic Shock Syndrome Induced by Group A Streptococcus with the emm28 Genotype That Developed after a Uterine Cancer Test. Intern Med 2021; 60:3481-3483. [PMID: 33994434 PMCID: PMC8627819 DOI: 10.2169/internalmedicine.6290-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
A 69-year-old woman without pre-existing disease visited our hospital due to general malaise, diarrhea, and arthralgia 3 days after a uterine cancer test. We diagnosed her with sepsis of unknown focus and started treatment immediately, but she died 20 hours after the first visit due to multi-organ failure and septic shock. Later, group A streptococcus was detected from the blood culture, and streptococcal toxic shock syndrome (STSS) was diagnosed. The strain had the emm28 genotype and a mutation in csrR with increased NADase activity. These virulence factors were considered to be related to STSS development in this patient.
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Affiliation(s)
- Yusuke Yamaba
- Department of Respiratory Medicine, Nagoya City University West Medical Center, Japan
| | - Osamu Takakuwa
- Department of Respiratory Medicine, Nagoya City University West Medical Center, Japan
- Department of Education and Research Center for Advanced Medicine, Nagoya City University Graduate School of Medical Sciences, Japan
| | - Chiaki Ida
- Nagoya City University Medical School, Japan
| | - Manami Saito
- Department of Respiratory Medicine, Nagoya City University West Medical Center, Japan
| | - Daisuke Kawae
- Department of Respiratory Medicine, Nagoya City University West Medical Center, Japan
| | - Misuzu Yoshihara
- Department of Respiratory Medicine, Nagoya City University West Medical Center, Japan
| | - Eiji Kunii
- Department of Respiratory Medicine, Nagoya City University West Medical Center, Japan
| | - Kenro Imaeda
- Department of Endocrinology and Diabetes, Nagoya City University West Medical Center, Japan
| | - Ichiro Tatsuno
- Department of Bacteriology, Nagoya City University Graduate School of Medical Science, Japan
| | - Tadao Hasegawa
- Department of Bacteriology, Nagoya City University Graduate School of Medical Science, Japan
| | - Kenji Akita
- Department of Respiratory Medicine, Nagoya City University West Medical Center, Japan
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40
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Deacy AM, Gan SKE, Derrick JP. Superantigen Recognition and Interactions: Functions, Mechanisms and Applications. Front Immunol 2021; 12:731845. [PMID: 34616400 PMCID: PMC8488440 DOI: 10.3389/fimmu.2021.731845] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 08/30/2021] [Indexed: 12/27/2022] Open
Abstract
Superantigens are unconventional antigens which recognise immune receptors outside their usual recognition sites e.g. complementary determining regions (CDRs), to elicit a response within the target cell. T-cell superantigens crosslink T-cell receptors and MHC Class II molecules on antigen-presenting cells, leading to lymphocyte recruitment, induction of cytokine storms and T-cell anergy or apoptosis among many other effects. B-cell superantigens, on the other hand, bind immunoglobulins on B-cells, affecting opsonisation, IgG-mediated phagocytosis, and driving apoptosis. Here, through a review of the structural basis for recognition of immune receptors by superantigens, we show that their binding interfaces share specific physicochemical characteristics when compared with other protein-protein interaction complexes. Given that antibody-binding superantigens have been exploited extensively in industrial antibody purification, these observations could facilitate further protein engineering to optimize the use of superantigens in this and other areas of biotechnology.
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Affiliation(s)
- Anthony M. Deacy
- School of Biological Sciences, Faculty of Biology, Medicine, and Health, University of Manchester, Manchester, United Kingdom
| | - Samuel Ken-En Gan
- Antibody & Product Development Lab, Experimental Drug Development Centre – Bioinformatics Institute (EDDC-BII), Agency for Science Technology and Research (ASTAR), Singapore, Singapore
- James Cook University, Singapore, Singapore
| | - Jeremy P. Derrick
- School of Biological Sciences, Faculty of Biology, Medicine, and Health, University of Manchester, Manchester, United Kingdom
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Group A Streptococcal Toxic Shock Syndrome after a Routine Gynecological Procedure. Case Rep Obstet Gynecol 2021; 2021:9980015. [PMID: 34211792 PMCID: PMC8205601 DOI: 10.1155/2021/9980015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 05/01/2021] [Accepted: 05/19/2021] [Indexed: 11/17/2022] Open
Abstract
Streptococcal toxic shock syndrome (STSS) is a life-threatening illness mainly caused by invasive group A Streptococcus (GAS) infection. Herein, we report a case of a postmenopausal woman who developed STSS from an ascending vaginal GAS infection after cytocervical sampling. The patient complained of vaginal discharge, for which she underwent gynecological examination with vaginal sampling. The following day, there was onset of diarrhea and vomiting. After 7 days, she was admitted to our hospital with septic shock. Necrotizing enterocolitis was suspected and surgical intervention was performed; however, the patient was diagnosed with primary peritonitis and antibiotics were initiated. On day 2, GAS was suspected by blood cultures, and antibiotics were changed in consideration of STSS. On day 4, GAS was confirmed in blood, ascitic fluid, and vaginal swab specimens, and STSS caused by an ascending vaginal GAS infection was diagnosed. This case report indicates that STSS could occur following cytocervical sampling for vaginal discharge. If a woman has unexplained septic shock, especially with gastroenteritis symptoms, STSS should be considered as a differential diagnosis.
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Cook A, Janse S, Watson JR, Erdem G. Manifestations of Toxic Shock Syndrome in Children, Columbus, Ohio, USA, 2010-2017 1. Emerg Infect Dis 2021; 26:1077-1083. [PMID: 32442091 PMCID: PMC7258457 DOI: 10.3201/eid2606.190783] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Data are limited on the incidence and management of streptococcal toxic shock syndrome (TSS) and nonstreptococcal TSS in children. We aimed to define the clinical patterns of TSS at Nationwide Children's Hospital in Ohio as they relate to published criteria, diagnostic decisions, and treatment options. Through retrospective chart reviews, we identified 58 patients with TSS (27 streptococcal, 31 nonstreptococcal) during January 2010-September 2017. We observed clinical and laboratory findings that are not part of TSS criteria, such as pyuria in streptococcal TSS (50% of patients) and pulmonary involvement (85%) and coagulopathy (92%) in nonstreptococcal TSS patients. Recommended treatment with clindamycin and intravenous immunoglobulin was delayed in streptococcal TSS patients without rash (3.37 days vs. 0.87 days in patients with rash), leading to prolonged hospitalization and complications. Incorporation of additional TSS signs and symptoms would be helpful in TSS diagnosis and management.
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43
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Cui Z, Lu S, Bai Y, Sun X, Tian P, Liu Y, Mao L, Jiang X. Necrotizing soft tissue infection: clinical characteristics, diagnosis, and management of 32 cases in Beijing. J Int Med Res 2021; 49:3000605211018442. [PMID: 34038197 PMCID: PMC8161891 DOI: 10.1177/03000605211018442] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE Necrotizing soft tissue infection (NSTI) is a rare but life-threatening bacterial infection. This study was performed to analyze the clinical characteristics of patients with NSTI admitted to the intensive care unit of a trauma and burn center in Beijing and to summarize the treatment experience. METHODS This retrospective study involved patients with NSTI admitted to the intensive care unit from January 2010 to January 2020. The clinical manifestations, pathogens, laboratory test results, and prognosis were compared between survivors and nonsurvivors. RESULTS Thirty-two patients were enrolled (28 men, 4 women), including 25 (78.1%) survivors and 7 (21.9%) nonsurvivors. The patients' median age was 41.5 years (range, 30.0-52.5 years). Mortality was significantly higher in patients with a blood urea nitrogen concentration of ≥11.5 mg/dL, creatinine concentration of <3.4 mg/dL, prothrombin time of ≥15.9 s, and international normalized ratio of ≥1.3. Streptococcus pyogenes and Clostridium perfringens infections were associated with higher mortality. CONCLUSIONS More attention should be given to elderly patients and those with hyponatremia, coagulation disorder, and higher blood urea nitrogen or creatinine concentrations. The finding of large gram-positive rods or large numbers of gram-positive cocci in wound secretion smears is a helpful early warning sign of highly lethal NSTI.
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Affiliation(s)
- Zhen Cui
- Department of Critical Care Medicine, Peking University Fourth School of Clinical Medicine, Beijing Jishuitan Hospital, Beijing, China
| | - Shuai Lu
- Department of Orthopedic Trauma, Peking University Fourth School of Clinical Medicine, Beijing Jishuitan Hospital, Beijing, China
| | - Ying Bai
- Department of Critical Care Medicine, Peking University Fourth School of Clinical Medicine, Beijing Jishuitan Hospital, Beijing, China
| | - Xu Sun
- Department of Orthopedic Trauma, Peking University Fourth School of Clinical Medicine, Beijing Jishuitan Hospital, Beijing, China
| | - Peng Tian
- Department of Burns and Plastic Surgery, Peking University Fourth School of Clinical Medicine, Beijing Jishuitan Hospital, Beijing, China
| | - Ying Liu
- Department of Clinical Laboratory, Peking University Fourth School of Clinical Medicine, Beijing Jishuitan Hospital, Beijing, China
| | - Lu Mao
- Department of Pharmacy, Peking University Fourth School of Clinical Medicine, Beijing Jishuitan Hospital, Beijing, China
| | - Xieyuan Jiang
- Department of Orthopedic Trauma, Peking University Fourth School of Clinical Medicine, Beijing Jishuitan Hospital, Beijing, China
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44
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Bruun T, Rath E, Madsen MB, Oppegaard O, Nekludov M, Arnell P, Karlsson Y, Babbar A, Bergey F, Itzek A, Hyldegaard O, Norrby-Teglund A, Skrede S. Risk Factors and Predictors of Mortality in Streptococcal Necrotizing Soft-tissue Infections: A Multicenter Prospective Study. Clin Infect Dis 2021; 72:293-300. [PMID: 31923305 PMCID: PMC7840107 DOI: 10.1093/cid/ciaa027] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 01/09/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Necrotizing soft-tissue infections (NSTI) are life-threatening conditions often caused by β-hemolytic streptococci, group A Streptococcus (GAS) in particular. Optimal treatment is contentious. The INFECT cohort includes the largest set of prospectively enrolled streptococcal NSTI cases to date. METHODS From the INFECT cohort of 409 adults admitted with NSTI to 5 clinical centers in Scandinavia, patients culture-positive for GAS or Streptococcus dysgalactiae (SD) were selected. Risk factors were identified by comparison with a cohort of nonnecrotizing streptococcal cellulitis. The impact of baseline factors and treatment on 90-day mortality was explored using Lasso regression. Whole-genome sequencing of bacterial isolates was used for emm typing and virulence gene profiling. RESULTS The 126 GAS NSTI cases and 27 cases caused by SD constituted 31% and 7% of the whole NSTI cohort, respectively. When comparing to nonnecrotizing streptococcal cellulitis, streptococcal NSTI was associated to blunt trauma, absence of preexisting skin lesions, and a lower body mass index. Septic shock was significantly more frequent in GAS (65%) compared to SD (41%) and polymicrobial, nonstreptococcal NSTI (46%). Age, male sex, septic shock, and no administration of intravenous immunoglobulin (IVIG) were among factors associated with 90-day mortality. Predominant emm types were emm1, emm3, and emm28 in GAS and stG62647 in SD. CONCLUSIONS Streptococcal NSTI was associated with several risk factors, including blunt trauma. Septic shock was more frequent in NSTI caused by GAS than in cases due to SD. Factors associated with mortality in GAS NSTI included age, septic shock, and no administration of IVIG.
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Affiliation(s)
- Trond Bruun
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Eivind Rath
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Martin Bruun Madsen
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Oddvar Oppegaard
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Michael Nekludov
- Perioperative Medicine and Intensive Care Function, Karolinska University Hospital, Stockholm, Sweden
| | - Per Arnell
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ylva Karlsson
- Department of Anesthesiology and Intensive Care, Blekinge County Council Hospital, Karlskrona, Sweden
| | - Anshu Babbar
- Helmholtz-Zentrum für Infektionsforschung GmbH, Braunschweig, Germany
| | | | - Andreas Itzek
- Helmholtz-Zentrum für Infektionsforschung GmbH, Braunschweig, Germany
| | - Ole Hyldegaard
- Hyperbaric Medicine Center, Department of Anesthesiology and Surgery, Head and Orthopedic Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Anna Norrby-Teglund
- Center for Infectious Medicine, Karolinska Institutet, Karolinska University Hospital, Huddinge, Sweden
| | - Steinar Skrede
- Department of Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Norway
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Fabian E, Wenisch C, Eisner F, Muhr T, Bauer PK, Prein K, Maierhofer U, Lax SF, Krause R, Zollner G, Weihs W, Krejs GJ. Clinical-Pathological Conference Series from the Medical University of Graz : Case No 164: A 46-year-old man with abdominal pain, dyspnea and rapidly progressing multiorgan failure. Wien Klin Wochenschr 2021; 133:731-740. [PMID: 33871688 PMCID: PMC8053743 DOI: 10.1007/s00508-021-01841-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2021] [Indexed: 12/22/2022]
Affiliation(s)
- Elisabeth Fabian
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Christoph Wenisch
- 4th Department of Internal Medicine with Infectious and Tropical Medicine, State Hospital Klinik Favoriten, Vienna, Austria
| | - Florian Eisner
- Division of Emergency Medicine, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Tina Muhr
- Division of Cardiology, Department of Internal Medicine, State Hospital (LKH) Graz II, Graz, Austria
| | - Philipp K Bauer
- Division of Infectious Diseases and Tropical Medicine, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Kurt Prein
- Department of Pathology, State Hospital (LKH) Graz II, Graz, Austria
| | - Urša Maierhofer
- Department of Pathology, State Hospital (LKH) Graz II, Graz, Austria
| | - Sigurd F Lax
- Department of Pathology, State Hospital (LKH) Graz II, Graz, Austria
| | - Robert Krause
- Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Gernot Zollner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Wolfgang Weihs
- Division of Cardiology, Department of Internal Medicine, State Hospital (LKH) Graz II, Graz, Austria
| | - Guenter J Krejs
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria.
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46
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[S3 Guideline Sepsis-prevention, diagnosis, therapy, and aftercare : Long version]. Med Klin Intensivmed Notfmed 2021; 115:37-109. [PMID: 32356041 DOI: 10.1007/s00063-020-00685-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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47
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Castro SA, Dorfmueller HC. A brief review on Group A Streptococcus pathogenesis and vaccine development. ROYAL SOCIETY OPEN SCIENCE 2021; 8:201991. [PMID: 33959354 PMCID: PMC8074923 DOI: 10.1098/rsos.201991] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Streptococcus pyogenes, also known as Group A Streptococcus (GAS), is a Gram-positive human-exclusive pathogen, responsible for more than 500 000 deaths annually worldwide. Upon infection, GAS commonly triggers mild symptoms such as pharyngitis, pyoderma and fever. However, recurrent infections or prolonged exposure to GAS might lead to life-threatening conditions. Necrotizing fasciitis, streptococcal toxic shock syndrome and post-immune mediated diseases, such as poststreptococcal glomerulonephritis, acute rheumatic fever and rheumatic heart disease, contribute to very high mortality rates in non-industrialized countries. Though an initial reduction in GAS infections was observed in high-income countries, global outbreaks of GAS, causing rheumatic fever and acute poststreptococcal glomerulonephritis, have been reported over the last decade. At the same time, our understanding of GAS pathogenesis and transmission has vastly increased, with detailed insight into the various stages of infection, beginning with adhesion, colonization and evasion of the host immune system. Despite deeper knowledge of the impact of GAS on the human body, the development of a successful vaccine for prophylaxis of GAS remains outstanding. In this review, we discuss the challenges involved in identifying a universal GAS vaccine and describe several potential vaccine candidates that we believe warrant pursuit.
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Affiliation(s)
- Sowmya Ajay Castro
- Division of Molecular Microbiology, School of Life Sciences, University of Dundee, Dow Street, Dundee, DD1 5EH, UK
| | - Helge C. Dorfmueller
- Division of Molecular Microbiology, School of Life Sciences, University of Dundee, Dow Street, Dundee, DD1 5EH, UK
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48
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Adigbli D, Rozen V, Darbar A, Janin P. Early intravenous immunoglobulin therapy for group A β-haemolytic streptococcal meningitis with toxic shock syndrome. BMJ Case Rep 2021; 14:e238472. [PMID: 33664027 PMCID: PMC7934773 DOI: 10.1136/bcr-2020-238472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2021] [Indexed: 11/03/2022] Open
Abstract
A woman in her forties was transferred to a Sydney (Australia)-based tertiary hospital, following presentation to a regional hospital with group A Streptococcus (GAS) otomastoiditis; complicated by meningitis, venous sinus thrombosis, haemorrhagic cerebral infarction and subdural empyema. She rapidly deteriorated with profound cardiovascular collapse. Despite initiation of high dose vasoactive therapy, she remained shocked and developed multiorgan dysfunction syndrome. Early intravenous immunoglobulin therapy (140 g in two doses) was initiated as an adjunct to antimicrobial, surgical and supportive care for refractory streptococcal toxic shock syndrome. Over the course of a twelve-day intensive care unit stay she made good progress with de-escalation of her vasoactive supportive care and reversal of her organ injuries. She was subsequently discharged to ward-based care. At her three-month follow-up appointment she had significantly reduced neurological deficit. Five months following her presentation to hospital she had returned to full-time work.
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Affiliation(s)
- Derick Adigbli
- Intensive Care Unit, Northern Sydney Local Health District, St Leonards, New South Wales, Australia
| | - Valerie Rozen
- Haematology, Northern Sydney Local Health District, St Leonards, New South Wales, Australia
| | - Archie Darbar
- Microbiology, Northern Sydney Local Health District, St Leonards, New South Wales, Australia
| | - Pierre Janin
- Intensive Care Unit, Northern Sydney Local Health District, St Leonards, New South Wales, Australia
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49
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Kunthavai PC, Kannan M, Ragunathan P. Structural analysis of alternate sigma factor ComX with RpoC, RpoB and its cognate CIN promoter reveals a distinctive promoter melting mechanism. J Biomol Struct Dyn 2021; 40:6272-6285. [PMID: 33554755 DOI: 10.1080/07391102.2021.1882338] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Alternate sigma factors play a major role in the survival of pathogenic bacteria such as Streptococcus pyogenes in adverse environment conditions. Stress induced sigma factors mediate gene expression under conditions of pathogenesis, dormancy and unusual environmental cues. In the present work, ComX, an alternate sigma factor from S. pyogenes has been characterized. The structures of ComX, RpoB β subunit and RpoC β' subunit of RNA polymerase have been predicted using comparative and homology modelling respectively and validated. Attempts have been made to study RpoB-RpoC-ComX complex interactions with Double Strand (DS) and Single Strand (SS) promoter regions. Stability of these complexes and the promoter melting mechanism have been analysed using Molecular Dynamic (MD) simulations. This study suggests that ComX, although identifies promoter analogous to the alternate sigma factor SigH of M. tuberculosis, follows a distinctive promoter flip out mechanism.Communicated by Ramaswamy H. Sarma.
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Affiliation(s)
- P C Kunthavai
- Centre of Advanced study in Crystallography and Biophysics, University of Madras, Chennai, India
| | - Muthu Kannan
- Department of Biological sciences, National University of Singapore, Singapore, Singapore
| | - Preethi Ragunathan
- Centre of Advanced study in Crystallography and Biophysics, University of Madras, Chennai, India
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50
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Torimitsu S, Abe H, Makino Y, Yamaguchi R, Motomura A, Hoshioka Y, Iwase H. Streptococcal toxic shock syndrome with fatal outcome: Report on four forensic autopsy cases. Leg Med (Tokyo) 2021; 50:101851. [PMID: 33578046 DOI: 10.1016/j.legalmed.2021.101851] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 01/28/2021] [Accepted: 01/29/2021] [Indexed: 12/01/2022]
Abstract
Streptococcal toxic shock syndrome (STSS) is a severe infection most commonly caused by group A streptococcus. It is clinically characterized by rapidly progressive multiple organ failure and septic shock. This report presents four fatal cases associated with STSS. In two cases (cases 2 and 3), the portals of entry may be ulcer and mucosa at the surgical site; the initial symptoms in these cases included fever. In the other cases, the portal of entry was unknown; the initial symptom was pain. In two cases (cases 1 and 3), malpractice was suspected before autopsy. At autopsy, blood culture was positive for group A streptococcus in all of the present cases. Although C-reactive protein levels were increased, procalcitonin levels were not markedly elevated. This is the first report of autopsy cases associated with STSS in which postmortem computed tomography was performed; the swelling of muscles and increased concentrations of peripheral subcutaneous tissue without gas may be characteristic findings. Histology revealed extensive bacterial colonies and necrosis with mild neutrophilic reaction in two cases (cases 3 and 4), and hemophagocytosis in two cases (cases 1 and 4). It is essential to perform appropriate examinations and make a proper diagnosis because STSS still has a high fatality rate and medical malpractice is often suspected. In addition, it is important to evaluate STSS again for the reduction of the fatal cases associated with STSS.
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Affiliation(s)
- Suguru Torimitsu
- Department of Forensic Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan; Education and Research Center of Legal Medicine, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan.
| | - Hiroyuki Abe
- Department of Pathology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
| | - Yohsuke Makino
- Department of Forensic Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan; Education and Research Center of Legal Medicine, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
| | - Rutsuko Yamaguchi
- Department of Forensic Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan; Education and Research Center of Legal Medicine, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
| | - Ayumi Motomura
- Department of Forensic Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan; Education and Research Center of Legal Medicine, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan; Department of Forensic Medicine, School of Medicine, International University of Health and Welfare, 4-3 Kozunomori, Narita, Chiba 286-8686, Japan
| | - Yumi Hoshioka
- Education and Research Center of Legal Medicine, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
| | - Hirotaro Iwase
- Department of Forensic Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan; Education and Research Center of Legal Medicine, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
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